GW1--06248_Well Construction - GW1_20230925

�W LY.,CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1
1.Well Contractor Information: 1
0 .1 ,, t�/' t✓4 v'14',WATERZONES=G:.vrti.:,: .i:"_r::l"<= .- -`ifi''1:._2:i -_,_..; .., ,,' .
FROM TO DESCRIPTION
Well Contractor Name 3 cos.
o ft. 7 a 0`ft. I I I 4)
30 3 64 ft. ft C e i/
NC Well Contractor Certification Number ^"'
:15r;OUTERCA.SING'(for:multi=casedi wells):ORLINER(i£ap lid ble) ': ,i::. .:c:_."•
Yadkin Well Company, Inc. FROM TO,,, -A- DIAMETER THICKNESS MATERIAL
ft. " J.*1 In. -- "
Company Name J ----•
"� 16::IICPTF.RCASING:OR=TIIBING:(geotIiermalclosed=laup)`r-C_._ =:%=::: (+
2.Well Construction Permit#: 0♦'1 ' y."2 0 2 FROM TO DIAMETER THICKNESS MATERIAL 7r et
List all applicable well construction permits(.e.UIC,Comity,State,Yariance,etc) .' / ft. LI " rj-lie ar k/ ? e,%�0 S � J
3.Well Use(check well use): - f4 it ® r in. 4/ <Preifild Ps4aa` ,
W rSu l Well: 17 S.CRFSEft. _ _---- : �:
Supply FROM TO DIAMETER _SLOTSI7.F THICKNESS MATERIAL
LfAgdcultural ❑�M♦/�icipaU it Public . ". it .in.
❑Geothermal(Heating/Cooling Supply) !ll#Zesidential Water Supply(single) 7 in. / �� CA
❑Industrial/Commercial ❑Residential Water Supply(shared) --- -—_ ----------- --- ----------------•-- . __.
xs
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPI.ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 a ft. L.,,LALed .YYi 6�` ,e d /2..,GJ
❑Monitoring ❑Recovery ft. ft. '^7 n
Injection Well: g ft,
❑Aquifer•Recharge ❑Groundwater Remediation 0
i?19:5'A D%G V L ACK-(if.appHcnble)-i::_'=_. =:=`_ _`_;.-` .:--.'' 1:.<
oAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
❑Aquifer Test ❑Stormwater Drainage '�.-
❑Experimental Technology ❑Subsidence Control ft. ft `/ V
❑Geothermal(Closed Loop) ❑Tracer 1:20::DRIMINGI:OG:(a-ttiicliadditiatikTi eets'ifnecessnry)=.== =' L.L.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,eta) -/a`-'l
Date Well Started It .fail' /� ft. ft.g
7/ ..L
4.Date WelI(s)Completed: q" " 3 Well 1D#AA '"7 L�7 0 i ep 6-1:,' CA
5a.Well Location: Phone#: i' 7� ft d ft. a
1-7.0"ryiN 64e1►M4:1 Ys ft. ft •
._
dsko� /iv
t �'Y
Facility/ Name Facility ID#(if applicable) ft ft Z-Z ' i �' "
/ ./ 3,r ..
. �a �eY"0 A..ft,1 �.h �, ft. ft.ft. 'rn 5 2UZ3
Physical Address,City,and ZipZS
Vet A k6 r. iZ1:REMARKS L:`'...--';"�____:::.' ,,- . -.Y� . :1 :�'�.i?n.."':�'r Z
::ytrwt:\::g IJ6
County Parcel Identification No.(PIN) DWl'`>•',(In '-'{
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 3
(if well field,one laUlong is sufficient) c(e.r 22.Certification:
a
��� �� N ra.>> ,e 360L: W 3
11 6.Is(are)the well(s): @Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 15A 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 been provided to the well owner.
repair under#21 remarks section or on the back of this fonn. 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 info041
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. t
drilled: 9 0 24.SUBMITTAL INSTRUCTIONS 00
9.Total well depth below land surface: A O0' (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different((xample-3 0'and 2©100) L..
10.Static water level below top of casing: 3 5 24a. For All Wells: Original form to Division of Water Resources (DWR), „'-
If water level is above casing,use"+" (D') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 �-
" o-'it a 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) a.
11.Borehole diameter: (in)$lt Off: a f
s Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ,fv s ar /es, ,-.A.,P 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
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) I Method of test: ,r-i 4t 0i Permit Program,1611 MSC,Raleigh,NC 27699-1611 (Let dA .
70% hth r Date Site Visited: I .
. 13b.Disinfection type: Amount: Ss- Oz Site Visited By: i . ( f�.,J' 'Pt.�.Q cc ' 'J
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Form GW-1 - . . North Carolina Department of Environ unlit -Division of Water Resources 0 Revised 6-6-2018
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