GW1--01676_Well Construction - GW1_20240315

— WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I : :.` '
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1.Well Contractor Information:
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��1.� �a4wAT�zoNEs� �,�7:. z;rxt,�,V ,,LTsq..v�_�.::,�-:�-' ,1..,
Well ContractorNae FROM TO DESCRIPTION
• ft. ft 1 I 1
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NC WellContractor� ft I.Certification Number
F..15°OVTE&"CASING'(fo'r•'multi aiied welli)':ORI,INFS WfiP- .Eable);�ar-•;%='cam:
Yadkin Well Company, Inc, FROM TO DIAMETER; THICKNESS LMATER/AL -1
ft. ft. • 'in. Ir
Company Name
.,16i•INNIR:CA.SING.010'QBING(geotlieiiiiii clown='Ioop)P; :* -AW,
2.Well Construction Permit#:;Al.?/4 is ®1 g 160- o i FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc) •.f ft 4/) ft Gad 1511L JI�-/( PVC
3.Well Use(check well use): • ft' ft in. !/
Water Supply Well: r7:7,tS_ : � ----=,.___�_.'-_v- - r." 7-'
FROM TO DIAMETER.. I SLOT CMS' THICKNESS MATERIAL
❑Agricultural • ❑•�unicipal/Public ft ft • in.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in. ! •
❑Industrial/Commercial ['Residential Water Supply(shared) _ls"GROUTi.M ;- - ,- ._------- ---,-;----_----2
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❑inigation ❑Wells>100,000 GPD. FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT p
Non-Water Supply Well: ® ft. 4/°' ft 3f9,1,i 1_m s tb1j rej
[Monitoring ❑Recovery ft. ° ft 01��� e�q�ei
Injection Well: ft �� ft �i ry�I �� el
❑Aquifer Recharge ❑Groundwater Remediation I •
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:aquifer Storage and RecoveryOSalinityBarrier 1 19i6AND/GRAS'I_ITACS(ifiarpplfelible)' ;._" _,:.=____ : _• • .
Q g FROM TO , MATERIAL EMPLACEMENT METHOD
[aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
• ❑Geothermal(Closed Loop) ❑Tracer .tl:D11.111 IGZOG'(sifts""hcarlai ioaal"sheets;if:necessa'ry")`,-^-==...=
FROM❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness scil/roek type,{gain size,etc.)
Date Well Started - ••` NG'� ® fr. ® ft ��, - ���� .
•4.Date Well(s)Completed)' u� `V Well ID# 5 #5'ft. p e' it. ���� ..... �� -?
5a WeIlLocat�op�q � " Phew;!#'3JG� Y0fe-///,� psi ft. " ' ft ' �t,T7�- ®�''9�' .
Facility/Owner N e FacilittyID#(if applicable) 0 ft ft
2-6 21 Arl ,9 tea®( .R.1 Y4A 41(.,•N 91le,NC ft• - ft. 4 L_,�Lo a.._r. �_ :• .: .
Physic Address,City,Tind'Zip fr. ft I. MAR 1 •`. 2024;
` 721 ity.B-rA ixs-f; _ _ _
County a k` Parcel Identification No.(PII� ^~ Y Ti` Ii1ii: iti�u•^1?��' �d Yv l}?.:,
V.aw�...:..
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5b.Latitude and longitude in degrees/minutes/seconds'or decimal degrees: •
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(if well filpeld,'orie fat/long is sufficient) . 22.Certification: -
Y�.. c7l9_514 N ar13-®573a7f . W " 414 •
- ' • 6.Is(are)the well(s): [ rmanent or ❑Temporary Si of Cc ' W Contractor Date C.71
_AA By signing this form,I hereby'certify that the well(s)was(were)constructed in accordance with 0.60
7.Is this a repair to an existing well: ❑Yes or fto 'ISA NCAC 02C.0100 or ISANCAC 020.0200 Well Construction Siandards 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 bee s provided to the well owner.
repair,under#21 remark section or on the back ofthisform. I '
• 23.Site'diagram or additional well details:
'8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of.this page to provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW�is needed. Indicate TOTAL NUMBER of wells , re)
drilled: a 24.SUBMITTAL INSTRUCTIONS
9:Total well depth below land surface: 64® ' (ft) Submit this GW-1 within 30 days if well completion per the following:
' For multiple wells list all depths if different(example-3Q200'and 2Q100) 0'
10.Static water level below top of casing: • (ft) 24a. For All Wells: Original forth to Division of Water Resources (DWR),
If water level is above easing use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 rp
11.Borehole diameter: ' (in.)Bit Off: 4,Oti I" 24b.For Injection Wells:Copy to IDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
� tar el t
12.Well construction method: y 24c.For Water Supply and Open-Loop Geothermal Return Hells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departthent of the county when installed
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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) Method of test: �'� I I 1 pie v✓ht 4•
70% hth Date Site Visited:/0-J'�;2 3 9
13b.Disinfection type: Amount: OZ Site Visited By: p 1'/I JpjTD S /Kt.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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