GW1--01623_Well Construction - GW1_20240313

• 1
'`WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only: ' k;
1.Well Contractor Information: ,y/y� a ch
�c3 1kA 9 0 /l,I'..,. rn n 0 I �B .> �0- t51-41 WAlti1t'•ZONESv'v ..n':::L.:,„1ri❑3::.:"»Y.-;1 ......_...�-> 0
WellCoatractorName II,
TO .•' DESCRIPTION np� -
(R S 6 —A • B30 ft.
11 1 ft. sow si , Yr"'� A
_a fG wit I, 111 •
NC Well Contractor Certification Number 15::0VrER:G'eLSING`(for mfrlti=cs'sed willi�:OR'LINER(ifsp"licable)=-=;rr_ 5:?:5 g
Yadkin Well Company, Inc. FROM TO DIAMETER` THICKNESS MATERIAL
ft. it in.
Company Name
Q D n ��A Q®� � Q, 13i6 NNER Ge1SING'OR':TIIBING; eotliei mat closedloo'p)'�i c _._.._..._:._.:=.-6
2:Well Construction Permit#: 9 R. L L. 4 ' FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.VIC,County,State,Parlance,etc.) 4' ( ft' 0 1- ft G,1-,.1 m- `COO- � rye.
3.Well Use(check well use): ft ft e� in.
WaterSn I Well: t17l'SCltEE1Yl.=" "_�7_ = ........2 '� .1-7==�-:.�:=_"=ks
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public , ft ft, - in.
❑Geothermal(Heating/Cooling Supply) lidesidential Water Supply(single) ft. • it tn. • '
❑Industrial/Commercial ❑Residential Water Supply(shared) .i85;GROUi•„M"" a-----` _- --____._�-__-
- ❑Iaigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nun-Water Supply Well: 0 ft' �°1) 'ft- 163�� 'g4-(. sp5 tb w ' d' ‘
%
❑Monitoring ❑Recovery ft ft. '�•�e f
' Injection Well:
ft. ft. , n
❑Aquifer Recharge .❑GroundwaterRemediation A� . °` �JZ4
I:191'SANli/GRAVEL•P.ACK(ifapp5he"alile)��' `=_ ', -- --"`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ' MATERIAL EMPLAPIMEJT.,METHOD
' ',i❑AquiferTest ❑StormwaterDrainage ft. it. ,/(,j}.,-"- ^n Lilo
''Experimental Technology ['Subsidence Control ft. 'ft - q
-OGeothermal(Closed Loop) ❑Tracer :c20:DRT7 iNGI:OG'(atti ch a3ditinriilrshei:teif ==..nec�ssary) =_�a,.�,�..7-
• FROM TO DESCRIPTION(color,hardness,satllrock type,grain slze,'etc.)
.OGeothermal(HeatinglCobling Re ) ❑Other(explain under#21 Remarks) y
••Date,Well Started Q`l L ',•` ft i d ft COille. l�a, -S t( g' ,.:
4:Date Well(s)Completed:6 I-10-114 WeII ID# e A, ® ) ( 0 ft �t ft: ' �,�. e,4,c �•-� ,
5a Well Location: Phone#:3.3C.-S�'/.�—S13'�' i •.. ,ft. 'F&-36 ft', 4�04 re,,R.• `i -
-1`�j �'v- itie s z vr\a. 15.0 .. (1 ,D m f t it rf,..E. u p , . ' `•/ ep
6.
Faaaelity/Owner Name . Facility ID#(f applicable)-. f 2:till-ft' ��� . wfe'c € f'gjq,
: W
9 II - Ape
n:,
w� r� ft- v t
Physical Address GYty and Zip ,v�iv 10+A6 — .___ _. _ •
q c:z
County, I r- ' Parcel Identification No.(PIN) -1' 5 t e• q i S ka.•' k 6a b t A- t r a(..J 'l'le'a J/
5b:`Latitude and longitude in degrees/nanates/seconds or decimal degrees: �'� F �o c" °-AH e
• • (if well field,one lat/long is sufficient) 22' tification:'
�, 2. C. .' N 0'O. i-T Me-.S J w . ci� " '�1 �3 1 .�14
Si 'of C ' ed Well Contractor " Date• ' .
1 ,j 6 Ls(are)-thewell(s): ermanent or •.OTemporary
�� .By signing 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 Q1Vo 15A NCA 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
'' this is a repair,fill out lonown'well construction information and explain the nature of the . of this record been provided to the well owner.
If C
repair under#21 remarks section or en the back of this,form. '
. 23.Site diagram or additional well details: • .¢$-
'8:For Geo• probe/DPT or Closed-Loop Geothermal Wells having the dame You may use the back of this page to provide additional well construction info P r
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. CA
drilled: / (� 24.SUBMITTAL INSTRUCTIONS 6*
-- 9.Total*ell depth below land surface: Y (ft.)
-For multiple wens list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
7 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: b (ft') formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in,)Bit Off: ‘o U a 5 24b.For Injection Wells:Copy.to DWR,Underground Injection Control(NC)
pp Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �P- 9 ` "��<6�l 24c.For Water Supply and Opew-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) t county environmental health department of the county where installed tp e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA "'�'
°[�q Permit Program,1611 MSC,Raleigh,NC?7699-16ii
13a.Yield(gpm) v4 a 5 Method of test: t
70% hth Date Site Visited: /-23 r 2-V
13b.Disinfection type: Amount: 1 i OZ Site Visited By: O'fift I I
1 '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018