GW1--06192_Well Construction - GW1_20230922

LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Cepts-, -/ i evwi---( (4 t :;14:':WATEIZZONES�:,:- _.:_:-"-,.,p,.�.*. • •:•=•`.-• - ....,..._ .. ..
We ConlractorName FROM TOq ! DESCRIPTION Q L
• ® (7_4 8 P• ft. 17 ft /S 6���RJ e' OLI. �L4tiC�
NC Well Contractor Certification Number .'15:OUTER'CASING(fu"r:multi=cosediweUs)•:ORLINER C i P 71e'able)Z_:=;. =1..• \SF//
Yadkin Well Company, Inc. FROM TO DLINETER' THICKNESS //M,AATTERIAL
Company Name I� a� le ( ft. g-Z/ ft. 6, in. 1i`6 , 6''1�-te ced e
P ' 1 L. d®�J�b 9 4 16:I R CASIN(G:OR.TDBIN�G'":`Oi tliermil lisego=166p)7w a.��.�.'1,:i7 ( {
2.Well Construction Permit#: (� FROM TO DIAMETER , THINNESS .MATERIAL .
List all applicable well construction permits(i.e.r1IC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft in. - _ -V` A f1
Water Supply Well: 71793'SCREFSR.:: .� ..____z-�_ - =
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M/uunicipal/Public f. it in.
0 Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ,:18:GROUT:;: :" -------_-- _--- ^ ___ -...--
• V
❑ltrigation pi:Walla>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:... .,-;~'.• •►� ft ft •�� p eft/ 14y i /�1 0
❑Monitoring L,: y'�Li i•" l ❑Recovery ft. ft I
0 (5® CA .i
Injection Well: • 2Q�J ft. ft
❑Aquifer Recharge S u .� ❑Groundwater Remediation
Ur:i Ei191:SAND/GRAVEL PACK(ifapplicabli) �:---- .- __-._--_7--.__.
❑Aquifer Storage and Recovery �,7-.;:Attig q in tty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 1tt;OLT 2'`'!•'A4 ,�<Y, Stomlwater Drainage ft. ft
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❑Experimental Technology 0 Subsidence Control ft. ft
OGeothermal(Closed Loop) OTracer ::2otDR[G'taNGI;OG'(ittae�'additioniral eetitifneeasary)_=" __-. -:..-
❑Geothemtal(Heating/,Roo oo o Return Other(explain under#21 Remarks) FROM T DESCRIPTION(color,hardness,sail/rock e, `�'n size,etc.)
Date Well 5tarted;� ) 0 ft �ft. 5 P It / 4 �0DS�. 5 v�
4.Date Well(s)Completed � 'Vell ID# 17:�"� 7 _ ft. r� ft /63Nmty„. ..ck ,-( y af,e✓j
5a.Well Location: Phone#:.� '�� 7- D �h� e D"1-7 n ft. I ft -.L -y 4oe f 4 - e.,a
S ✓tnaxl..l's'T sa�)S + `1e6y-/'ei'Ir•-Le✓s t'J $ I 4,' ft. /1 22 ft L/-� f_y€,5! C- ->'j.6d00 /&L1�C gwc
Facility/Owner Name ✓✓ Facility ID#(if ipplicable) ft. 4/ ft
cibn ft. ft IIPhysical Address,City,and Zip J o yC ft. it
-.'--9----([--_(__. _J /_.��_ ._..
County Parcel ldentification No.(PIN) -I', _ t& ! '/ '"i ,tT 6C�4r`- -- tic.t e '--i ( P Vo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6e. ex S'e- t e a:5 if.-
(if well field,one lat/long is sufficient) 22.Cer till.,tion:
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36, 5g 2..1 ct 1' N O, 1 '--/r.9 3 a. w F ) ��
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6.Is(are)the well(s): iermanent or ❑Temporary • of •Certified weal Contractor a e
:r signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or C11Vo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has beers provided to the well owner.
repair under#21 remark section or on the back of this form. °
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL-NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: f� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: %'�� (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2Q100')
d® . (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" -'y
11.Borehole diameter: On.)Bit Off:4° / 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
r� Q Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: isr r 04 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the _
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA L
3
Permit Program,1611 MSC,Raleigh,NC 7699-1611
13a.Yield(gpm) / Method of test: r" 4'..{'4'® -- 4P1'e""°r' Ye 4.
11
Date Site Visited: Mai a:��,B
70% hth I I OZ Site Visited By: • I' E.
13b.Disinfection type: Amount: �
Form GW-1 - North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018
Price:_