GW1--00552_Well Construction - GW1_20240125

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- WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �`
� 11'0/1 E L�,�1•V G E..14:;WATEIt`zONEs >ivt:�3' r.-c:' _•--..?°s"'t. :1-
Wel C tractorName FROM TO ~'DESCRIPTION -
"l '(a ! J ft ft .1
NC Well Conactor Certification Number 15.TOU2'P:it'CASING'(fo-r:multecased;fvells)-.ORLINER:(if`ap licable)e:'....•' r
Yadkin Well Company, Inc. FROM TO DIAMETER TTIICIINFss MATER/AL
ft. ft. in. e"Company Name 11165INNEIi:CASING:OR.LUBING eotherna1cloaed=Ioo 1-1;.:=_':"3:.'.-,-
2.Well Construction Permit#: 3q0cliC, FROM TO DIAMETER THICKNESS MATERIAL n
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ' . 1 ft. �.9 f. 6, ()- in. S l�ni .1l P (l _
3.Well Use(check well use): ft. ft. in. J( / !/
Water Supply Well: J7:gCRE __1 71--._-__—: :_ _ __7-1':': .':-,�
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ftr1/4' z s vim /�
{ OGeothermal(Heating/Cooling Supply) tesidential Water Supply(single) ft. ft. w� "
❑Industrial/Commercial ❑Residential Water Supply(shared) ,18 GROVr,:::= :-777-2:_ ti_:--:7-1 r 7 :--,"=1•• _c..--
❑Icrigation • ❑Wells>100,000GPD FROM TO ' MATERIAL EMPLACEMENT METEOD&AMOUNT LI)
Non-Water Supply Well: ® ft. !ft. Oi n ta-i i I t C�•S to���� ® Ci
❑Monitoring ❑Recovery ft. 6 ft. r p �r /�
Injection Well: ft. ft
�G f
DAquifer Recharge ❑Groundwater Remediation
is19YSAND/GRAVEt)PACIC(if 1plicable)f.`aa1=���_ _ :.:::::as;��?
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft
❑Experimental Technology ❑Subsidence Control ft. ft'_ �---
OGeothennal(Closed Loop) DTracer C-20;DRIG'tIP7GIAG'(a-ttachadditionaIsheetati',necessary):.:.._..,:._____-N=0
FROM TO DESCRIPTION(color,hardness,soillroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
Date Well Started D. L —a3 0 ft. (' ft. So.,-l
4.Date Well(s)Completed:I2 e 123 Well ID#A A P"t 6 3� 3 1 ft 5-o•1 ft `il b,_p ,a/ c/an l'i,
5a Well Location: Phone#:3 —a Go— 10 d ft. ft V 5 �1
a ft. ft.
SUS AA immn®5��1
- • Facility/Owner Name r Facility ID#(if applicable) ft ft % r T^^-^
Si2,04-L E G2�a�T Cr�!M l-3.(. w•r i• 9 :
ft ft ff t
Physical Address,City,and Zip �, ft. ft _J H N 2 6 2074
County Parcel Identification No.(PIN) rso..., , 1/41)1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) . 22.Certification:
6.Is(are)the well(s): i°r•`ermanent or ❑Temporary Signs of Certified We Contractor ate
By signing this form,Thereby cero;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or To 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 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: 1 S 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J 0,2 (ft.)
For multiple wells list all depths if different(example-3(4200'and 2Q1100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: )00 k (ft.) 24a. For All Wells: Original form to,Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)13jf Off: 3 : /0) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f 0'f An( /'4� 24c.For Water Supply and Open-Loop i; _41 Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed • t
°
FOR WATER SUPPLY le ONLY: '
1 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCYCUA t
. Permit Program,1611 MSC,Raleigh,NC 27699-1611 r :J
13a.Yield(gpm) 9.- R Method of test: A'`A lk 1 r
700/ hth /1"2 Y' 2373
13b.Disinfection type: Amount: Oz Site Visited By: S...t
(Z` ` Revised 6-6-2018 .0 I
Form GW-1 -.North Carolina Department of Environmental Quality-Division of Water Resources ' -
Price: i -