GW1--06927_Well Construction - GW1_20231027

' °' ' W�ELp CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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' 1.Well Contractor Information:
C r D IA -e- / -.-Y-:P✓✓'t 9 F14?wA.TER•LONES'3i. .,ir?',4"ti:;"l." .:i:-0%'�r:-': I_a.,::z.. _ . .
FROM TO DESCRIPTION` Itli
Well Contractor NameI✓1^
�^�ft. �ft d q�
�� ft. !N , ft 1
NC Well Contractor Certification Number '15:OUTERCASING(frlr'midti=casedweIIs)AR`1:.71EIt'(if.'s"•licalilef"; ' ••.•1: '
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
4- I ft 6 3 ft. 4.91-S in. /P$$ G.-/vt,,.,,,t.d.) ��
Company Name +�pp � e� / '16:INNERCASING:OR'.TTBING(geotlietmil'ilosed=loop)r.2 "`"'-'."-=" 5�:7'.z•a•
2.Well Construction Permit#:1/J,7 ° .2-— ® I i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.) ft. ft. in. ;
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE ,THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) [residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18 GRO1TI.rSii_ ...ten"-.•�v/.s,:.. fy ..
❑Irrigation ❑Wells>100,000 GPD FROM TO j MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ® ft' QV— ft fif,t `k cL fYnj rd.- r:. lee-c..
❑Monitoring ❑Recovery ft. ft t y_(.50 1..g b 5`,
Injection Well: ft ft >
❑Aquifer Recharge •❑Groundwater Remediation » — _
1:i19'_�SANIiIGRAVFniACE:(itaii0faile)w' _`::��- =: �'
❑Aquifer Storage and Recovery ❑SslinityBarrier FROM TO MATERIAL EMPLACEMENTMETHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer G20tDIlILPJ11G•ZOG'(attiir�additiounl'sheetrif.neensary) :-...., �. ,«= '
PROM TO DESCRIPTION(color,hardness,saillrock type,grain she,etc.) "
❑Geothermal(Heating/Cooling Return) ❑Other(explain underl#21Remarks)
Date Well 5tartedb7/Sad /°d3 ft /(3 ft �o If / �r ca):�_
4.Date Well(s)Completed Dd$r/'fit,{ ;/?3 Wen n0# AA�'� /� ft. 43 ft R a,t k, •y.eL S f 6c y,44, L
Phone#•Sa Well Location: Kg f 9� ft fl.,c/Si i..t .c,rS!
( G3/', � _
Zle „ye...1,a•s C,:p� ft ft
Facility/Owner Name Facility ID#(if applicable) ft• ft. a
3Si1 Tv.vi.fr v,l 'Tie/, / 4°Aer''1 Q— Wr f. ft -� '.J� rY_
J >L- ;r'__
Physical Address,City,and Zip 31, ft ft.
County Parcel Identification No.(PIN) 1 In,orm:+: n: ._
... 'g Utz t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees D'.'.;`‘—'3 G
(if well field,one lat/long is sufficient) 22.Certificati n: 'v
.e- ----1"/Z------. 0 Si7.5;7144,4-.) 3
6.Is(are)the well(s): li ermanent or ❑Temporary Siv.. .>entrfiedwelIContractor Date
••-"ing this form,I hereby certify that the well(s)was(were)constructed in accordance with (J)
7.Is this a repair to an existing well: ❑Yes or (l10 A 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 t e of this record has been provided to the well owner.
repair under#121 remarks section or on the back of this farm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '7 4` (ft) Submit this GW-1 within 30 days of well completion per the following:
Far multiple wells list all depths if different(example-3(a)200'and )2©100
50 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), •
10.Static water Ievel below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter: 6 (in.)Bit Off: e•i 13 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) ;
Program,1636 MSC,Raleigh,NC 27699-1636
_
12.Well construction method: i^ p.. , 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) bounty environmental health department of the county where installed 9
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) v Q Method of test:14:d� PLAdf
o Date Site Visited: 1-7
. 13b.Disinfection type: 70�o hth Amount: 1� Oz Site Visited By: I '
E
Form GW-1 _ _ _ North_Canolina.Denartment ofEn.vironmental Quality-Division of Water Resources; Revised 6-6-2018 " j
Price: I a�:6