GW1--00619_Well Construction - GW1_20240125

7YL4,CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well// �Clontractor Informations:.! I
(Yea -ege.. e. /AA L>X!I WA.TL'R-ZONBS'._�-. .li5"-=:_ti' - , r"._f�`'? �.1....v .,:.ii:.,
Well Contractor Name i FROM TO DESCRIPTION
vY' aSS ft. Citt.ft...a6 6P,l'1't z
ft. ft .,
NC Well Contractor Certification Number I r ;,!;: s�
15ZOUTER CASING(for•.mull?ca'sedw"ells)ORL N R(ifaplflu
liaable)T p.
Yadkin Well Company, Inc. FROM TO DIAMETER . THICKNESS MATERIAL J,
., . 4 / ft. .71 ft G,/2S;in: Sp/1''/ CCj
Company Name >e�a,. 3ry "- ` 69 D 31S-Y i1611PINERCASING:OR.TUBING:(geotliermalclos`ed=ldop)'" ----,-.--r f
2.Well Construction Permit#: 2 OE 1 0 1 FROM TO DIAMETER THICKNESS "MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft. ft. in. (Li(.)
ft. ft in.
3.Well Use(check well use): ___�__,_____ _.__.__._
Water Supply Well: 37 SCfitati 7."_.. `_-;..'` _-__�.._
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MM�unicipal/Public • f. ft in..
__
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18 GROUTI __.":, v_--.7--...._ v` e�
❑Irrigation ❑Wells>100,000 GPD FROM TO/ QQMATERIAL EMPLACEMENT METHOD&AMOUNT 0
Non-Water Supply Well: • b fr' O'� ft sge.�a+t• (4 /'7 y dPyl Vq PA e t
❑Monitoring ❑Recovery ft. ft vA
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
i
19:SA1\TD/G12AVBETACK'(if.applicabl e)7'.:.,_:_.::.r "���_:.:='T /I�•�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ZMPLACEMENTMETHOD .
❑Aquifer Test ❑Stormwater Drainage ft. ft .-I,
[Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer F20111RILLINGI"OG:(attlielatdditlona7'sheetsifneeet any)`== �"_. --:"€
FROM TO DESCRIP"IION(e la,hardness,sail/rock type,grain size,etc.)" ,-
❑Geothermal(Heating/Co ling Ritual) ❑Other(explain under#21 Remarks) 0 ft. [O ft. So�! P \
Date Well StartedQq�,G,t1t7 /'3 .1 / ,, ,J
4.Date Well(s)Completed:20/i}ot?/' S Well D)# AP- 11.1 s2) fr" t 5 ft. �^Q ✓,/ 1//oW v.� GYM-tJ A` C
ft, ft oee5 Grp - off•
5a.Well Location: Phone#: / 9 j�p G+�S 7 61 R / y �.
r / " 'j014 Siik;1r` f f i I41 B' sta ft. �ael5i la.eyl£A,'/t�G.etyr-S n
t f & S 1 a-t-e // 'I ft. ft
Facility/Owner Name �y ]��� Facility
rID#(if applicable) __
i 41`r'k 1�-l..YSete. v l te.d
ft. ft. !-',i:'"x-• rt" , .. ;F'"
Physical Address,City,and Zip __- /�
�°I/, .1 4 Z1'•:RF,MARKR"`"'". ..��."., .JH�:.1_ ...�__fl!1-Y_:,�L..---..._:F V=.
County Parcel Identification No.(PIN) ~~` iT,V i `n_ f
lAl
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -...y..a
(if well field,one laUlong is sufficient) ( 3 0. 22.Certifica:•n:
N '30 s OS ACariPEW' ' . p.4„,,, 30/-a.„,....46,frop .
jt a of Certified Well Contractor' Date
6.Is(are)the well(s): flafermanent or OTemporary ..:""
y 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 AK 15A 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 remarin 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-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: J2 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2@100)
/iD (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: '7 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)13jt Off: (L-( 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1(ies
ft®'f tt y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA `k.
Permit Program,1611 MSC,Raleigh,NC 27699-1611 "4
Method of test: i l � � s' °�
13a.Yield(gpm) � ,g
70% hth Date Site Visited: 7-,a:-- �;_ 3
13b.Disinfection type: Amount: 13 OZ Site Visited By: Pi , -st, ;�
Forni GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018 ?��
Price:; - i ,
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