GW1--06889_Well Construction - GW1_20231030

G
-• L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infation: I 7'
Cer.)) - -envi,e/ i, . '14 wATER7ANFS ia,'::. :7TQ ":3:« ~ti ,...,. .,..T f, 4::, :' -
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FROM TO DESCRIPTION +
Well Contractor Name t!�4 36{t. 4® ft1611„."® I��
�3 d� � ft ft I rri
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NC Well Contractor Certification Number .15 OUT'EK'CASING'(fo"r'mulfi=cesed`_wells).ORLINER(ifap lieable)r�-7:::," ..: ' S
Yadkin Well Company, Inc. PROM TO DIAMETER I THICKNESS c
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+�l f t 5'`�f t 4,19S in. VI`�R 4 I 1/
CompanyName, �„ ��G, l:� �e ��H j'
b.6:: R..CASING:OR.TUBING:ffe itliermaIClo`se`d=loo irA,!_?_��
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2.Well Construction Permit#: f f 14/L, 2b22.01 S"7 2. FROM To DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft 1 in•
ft. ft i in.
3.Well Use(check well use): _ _�� ���
Water Supply Well: it 7•SCRE1SS:...:.3'- ��:.s��_:.:� .' �__ �._..
FROM TO DIAMETER SLOT SIZE T THICKNESS MATERIAL
❑Agricultural OM cipal/Public ft ft. in.
oGeothermal(Heating/Cooling Supply) D7Residential Water Supply(single) ft ft in-
Olndustrial/Commercial ❑Residential Water Supply(shared) :.18 GROU1 =: '_"'7 -"` L----:-T'
Olrrigation OWells>100,000 GPD FROM TO MATERIAL EMP S1a US METHOD& MOUNT
, Non-Water Supply Well: �, ft a( ft IB,vtby„f.C,Ia 14 o d& $� G-G�
OMonitoring ORecovery ft. ft d j 1�"
Injection Well: ft. ft
OAquifer Recharge .0 Groundwater Remediation - -
119::SAND/GRAVELPACEC'Crfnppirchlile)., �� :.�_:`- __-__--.
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL LAMA-CEMENT METHOD ••
• OAquifer Test ❑StomiwaterDrainage ft. ft.
. . OExperimental Technology ❑Subsidence Control ft. ft
,, ❑Geothermal(Closed Loop) OTracer 1.7:20:DRIT TGIAG_(s"tt.el addit[onal"sheets ifnecEssary)1`•'" .
FROM TO DESCRIPTION(color,hardness,soWreck type,grain size,eta)
OGecthermal(Iieating/Cooling Return) ❑Other(explain under#21 Rranarks) b ft Q ft S�rr I
-Date Well Started//A/0vfi, 1
4.Date Well(s)Completed:/a O cf 3 Well ID# l 0 A e ft 1 f 5 ft �-ee5 1 Pack f ._s 0., I
' 5a.WellLocation: Phone#:336-.374'-e>'.3 If S ft S ft �ryr�rt..`/c- !� 0 CA ,
/../..ze,, , -k-k- 5.'7 ft. g6oft. Cee--Kg`te
Faoiiilityy/Owner.Name !,, /� r-�, r FaccilittyID#(iifaap/plic/a�bl�e) ft ft
�l 2 to k,--fe gu. rQ W t ( L` ,its vr ft. ft �' °y `v• ' +
Physical Address,City,and Zip (�( __�'"b"`
�/�� • n21:RFM:dRXS _� .._� -_.. -..."__�._...�.111-"„1�%�,/l_7n "-� 's
kyf..2..
v c02,3
- - :bounty Parcel Identification No.(PEN) ' } ;' c. 's
Sli.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1'a` .:.�m^`71 Li-
(if well Eeld,one Iat/longis sufficient) 22.Certific'tion:
Li
, y ,,r37 N g� C�' 4� 7P w` . '14,ra 1619:::
6.Is(are)the well(s): iffermanent or OTemporary a,gna of Certified Well Contractor pate
: '`gning thisfonn,I hereby certify that the well(s)was(were)constricted in accordance with
Q 'SA 02C.0100 or I5ANCAC 02C.0200 Well Construction Standards and that a copy
7.Is this a repair to an existing well: OYes ,ar t�
If this is a repair,fill out known well construction information and explain the nature of the ofthis 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constriction info
construction,only 1 GW l)s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: P , 24.SUBMITTAL INSTRUCTIONS 5
9.Total well depth below land surface: 6 (ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdifferent(example-3@200•and 2@l00')
24a. For All Wells: Original fo Co
rm to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (ft) Information Processing Unit,1,617 MSC,Raleigh,NC 27699-1617 (.)1
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)E3lOff:®r 07 24b.For Injection'Wells:Copy to DWR,Underground Injection Control goo)
C`3o Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Pf:Ir1 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 Q
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA --
�e Permit Program,1611 MSC,Raleigh,NC 27699-1611 � r � L tt
13a.Yield(gpm) Method of test: V" 7-
70% hth oz Date Site Visited: ,3 -2.3
. 13b.Disinfection type: Amount: CP
it i Site Visited By: D M i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 d-2018 i