GW1--07482_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD (GO6l-1) For Internal Use Only: 1 .
I
I.Well Contractor Information:
(l .711k A, A f 0 &LI 4 car ,WAIT ZONES 11 ...::`:;:i^:tOt`:`:`'" :• Ya-'.t• .1 :,—:_
Well Contractor Name �F%ROM TO DESCRIPTION
3036 • 6%��it. 3��ft
NC Well Contractor Certification Number
�S el I ft p� ft
315:OUT'ER'GASILNG'(fur•mulls,:elied'wa11.CORLINEIC(if -tien-ae)-= i
Yadkin Well Company, Inc. FROM 0a,AITRIzTaIcKN>ss MAsSRru.........,,
ft.
Company Name _ _
P Y s ®o�� u165IND ICASINa012:0:utfiNG(geotbaiiiii cld ed=laop)z's= __—__:.L. `.ai
2.Well Construction Permit#: 0 i FROM TO -DIAMETER _THICKNESS MATERIAL
List all applicable well construction perntiir(Le.UIC,Cow*,Stare,Variance,etc.) 4' ) ft. 106 it p V II in. l fo®`-a, P vC,
3.Well Use(check well use): • ft it ! in 0�
Water Supply Well: a"1-.7uS` ,i _ 11.__T__._-.--_-_- _�T_=;`�=
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
DAgricultural OMunicipal/Public// ft it in.
0 Geothermal(Heating/Cooling Supply) l3Residential Water Supply(single) ft m. „....,,,/••'''''*''-
❑lndustrial/Commercial ❑Residential Water Supply(shared .0:8 --------------—_ .__r-:--_._.___-._____---___ - -_
❑Iu P
igation ❑Wells>100,000 GPD FROM TO MATERIAL EMT -METHOD&AMOIINT
Non-Water Supply Well: 6 ft air ft. ,R k,„,e ,i. 6r44,
❑Monitoring DRecovery ft ft
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation _1_19 3ANti/611AvEBTACK(ifapplicaDle).-_-__--_ _----:- --- ---__-..:_-'. . .
❑Aquifer Storage and Recovery DSalinityBarrier FROM To MATERIAL•- EMPLACEMENT METHOD ' •
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Pxperimental Technology OSubsidence Control .„?.../7 (��
❑Geothermal(Closed Loop) OTracer :20DR.1:ETZNG'I:OG'(atlacliaddittonalsheetrifnecaasry)•2_____=`-___�._
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started ➢v,o 30-,.3 0 ft' f- it. Se )
4.Date Well(s)Completed: /a-. 1-43 Well ID# A A P gI 4 9.j ft 3 L 0 ft. _6 re A 1. s �,g_ //g g2
Phone#: [phone]— Ca793 ic. ft "'�
Sa Well Location: �0 4�'Z Ses44-- 6 Teo sas' 2r :
ft ft.
OVA/4?.. �I- --oa�,`� GPD' - 4.--' ">:-- y
Facility/Owner Name I Facility ID#(if applicable) ft. ft
ft
Physical Address,Clttand Zip ft. ft in;,, ..-
County Parcel Identification No.(PIN) /vim r ft, l .c.c( ijp.6 ie.f G,4%a"0j
4
- Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: q' �n�al on C°a t• 1,5 .
(if well field,one lat/long is sufficient) 22.Certification: y�
3s° 31/ I N 50°) S'i 'Si w
6.Is(are)the well(s): e ❑r ermanent or Temporary Signature of Certified Well Contractor Date
r p L fue, 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 NNo 9 0 . /ti Val NSA 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 naY,rre of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofilds 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 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: [ LI 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
0 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"+"
t as �® 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
II.Borehole diameter: (in.)Bit Off: 6+ 0-9
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: (tea1T 4' Ptaj I a 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
k.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
¢'
Method of test: t 4 ( (ll•
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
F
70% hth 9 Date Site Visited: JO®.2it�A Al
a
. 13b.Disinfection type: Amount: OZ Site Visited By:
—.dig k a4$07
Form GW-I r _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 6-20!8
i