GW1--06888_Well Construction - GW1_20231030

-- LL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
3
1.Well Contractor Information:
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if / /W). FROM TO DESCRIPTION
Well Contractor Name
CJ 3 -fi S ft. at/0 ft t 1 �t/i
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NC Well Contractor Certification Number ;•15 OIITERCAS1NG.'(foimniti=sased:weifs)OR"L3NER•(if ap-licable)�:_ '; i'.,•::
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS ��/MATERIAL
t'el
ft. 51 ft. ca/pS ,in. 5AV If (fie
Company Name Su
VPr 3G' E y :116INNER�CASING:OR:TUB)NG;(KeotlierTialdoTedabliii),V=: -.1.;:_ ._
2.Well Construction Permit#: Pit(�L. 2.023 0,06.4- S FROM TO DIAMETER _ THICKNESS MATERIAL
List all applicable well constriction permits(.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROMCRTi.'.E TO-4V DIAMETER`x-SLOT SIZE THICKNESS MATERIAL. .-•,
❑Agricultural ❑MunicipallPublic ft. ft. in:
❑Geothermal(Heating/Cooling Supply) Idesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) - ---- - _ -_- -
• �"18..GROUT*:. -7-1_ _.
❑Isigation ❑Wells>100,000 GPD FROM TO MATERIAL ENIPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: a 3 ft. 0 ft 4400 �C/g/'/, i, d,„, 6' ���h -<-
❑Monitoring ❑Recovery ft. ft. 96r7
d��+ 46 bno5
Injection Well: ft. ft �!
❑Aquifer Recharge .❑Groundwater Remediation
it 19.-SAND/GRAVEL-PACK'(if:'applicable) Y ^ .
❑Aquifer Storage and Recovery ❑Salinity Basler FROM TO MATERIAL EMPLACEMENT METHOD ' '
❑Aquifer Test ❑StormwaterDrainage 8. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
0 Geothermal(Closed Loop) OTracer :201IUM tINGI:oG:(attirchitddittlifial"slieetiif.necasary)r-" "- ==
❑Geothermal(Heating/Co•-.g Re ..) ❑Other(explain under#21 Remarks) FROM TO DD]ISCRIPTION(color,hardness soil rook type Brain size,etc.)
Date Well Started/3 e7 e9 ft /f/ ft' -7 • I '�- 4 005 e SI- 14-e r
4.Date Well(s)Completed:/7/Oe. g Well 1D#A AP' 2 3-7 4( ft- J 1 ft. A 0 .A. , C�-fi£y,. '2� " /-a-e5
Phone#: 3,;3c,- y,Y2-%/ ft. ft. /
5a.Well Location: /, S� �� go ��y /�9-G J�,- (f 4^
Lynn► t711 ina P"3t!g- S'2C-/k2C C®2. ft Y� a�• ft RDG��. , 6iey1 )A Xt.. ',ye 1ZO-/)&
Facility/OwnerNamey •• y� / �F/Jacility ID#_(i-f applicable)- a ft
s b "2 /'lu A vl Tt1I)I .1 1 hu e-a ft. ft. •
Physical Address,City and2iji ft. ft. ',: + ,4. ^'` - ,��
Cali-RF11LRKRSZ.17 ; �.�a_2...._ V�-_ .1:.._ .-:r-i'.2-krL37_ .
County Parcel Identification No.(PIN) OCT 3 0 2023
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !r..`�;;;;,:::._,,I' y F
(if well field,one lat/long is sufficient) \\ . cation: '' •:y i�T;.
� .r ,� ®3 N g4r ia .� W -c i- -ge
�.�'<.. /7 �C VSGV/7&)3
6.Is(are)the well(s): l4'permanent or .OTemporary Si:':titre of Certified Well Contractor ; Date
�� : signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
• 7.Is this a repair to an existing well: ❑Yes or ibl �,_ 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction it formation 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 form. 23.Site diagram or additional well details: C
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 th
(add'See Over'in Remarksmay also attach additional pages if necessary.
construction,only 1 GVJ-1 is needed. Indicate TOTAL NUMBER of wells Box).You C}�
drilled: i 24.SI BMITTAL INSTRUCTIONS -
9.Total well depth below land surface: ® A. (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(esample-3Q200'and 2@100)
(ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Infommtion Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" p�
11.Borehole diameter: (in.)Blt Off: e• 0 (a 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IOC) .
/ Program,1636 MSC,Raleigh,NC127699-1636 G
12.Well construction method: fi r�� R® Y 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 SUPPLWELLS ONLY: t 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) rj.f t Method of test: 4 1 ✓- Permit Program,1611 MSC,Raleigh;NC 2769 9-1 6 1 1 W
° Date Site Visited: g-f(-;23
13b.Disinfection type: 70/O hth Amount: t9 OZ' Site Visited By: p373CO
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018