GW1--02310_Well Construction - GW1_20240410

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: - `im
` of
6• aiAdS l"`l\ UifiVATE$'ZONES'�:2i.:1;3£vi:' ''11.1L'iiXr-1-15':L. Zi.:ut.�.-2.1.:.$:K.";Ci
Well Contractor Name FROM TO _ DESCRIPTION!
rya it y'fr1- ft .(i I /- -.— t/y, ft-, t�i� -v-
�f 4610 A- ft. I. ft • I
NC Well Contractor Certification Number t15::0IITEEt:CA,SlN. '(foimulfieased7alli:OR'LLINF�R;(ifip"licable)e�..,; ::' ?:�"�`:
Yadkin Well Company, Inc. FRom / TO jc DLAT Iin.
_ T res S MAT7RAL
ft. r ft (/•
Company Name / C.,'
`� 116ANNEROASING"ORTIIBING(geotlieriiialelos3=1aop)h '" ..="` .. ..f . :b::J •
2.Well Construction Permit#: `_+ 1 `�j a ojv mom TOq DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(t.e.WC,County,State,Variance,etc.) .�d. 1 it („1, ft 6,1 �..5 m' Set( I �l/G-
3.Well Use(check well use): ft. f[� ft. in.
Water Supply Well: '17 SCRLE>_�1.t_:_`'•.-."_._ , _� "`- 7-'-_.
Pp Y FROM TO DIAMETER SLOT S THICKNESS MAT
❑Agricultural ❑Municipal/Public f ft. in.
❑Geothermal(h eating/Cooling Supply) vie esidential Water Supply(single) ft / ft /in.
�_ -._
OIndustriaUCommercial ❑Residential Water Supply(shared) i_FLIGRoDTt.,;_. --rr — 5- .): .-
❑lrrigation ❑Wells>100,000 GPD ' FROM cT�O MATERIAL EMPLACEMENTMEfTHOD�&AMOUNT
Non-Water Supply Well: 0 ft o f ft. /i�t''�� G t/�j+t jt� ' !J ��S
❑Monitoring ❑Recovery ft ft. •
v�
Injection Well: ft. ft.
❑Aquifer Recharge •❑GroundwaterRemediation ' • �_ _ _
i 19 SAN1)/GRAvl.l+ .PACIV(tfspp cable).. ___ _ .
❑Aquifer Storage and Recovery ❑SalinityBartlei FROM TO MATERIAL r EMPLACEMENThtFTHOD '
-.❑Aquifer Test ❑StormwaterDrainage ft. ft
DExperlmental T gy
ecbnolo ❑Subsidence Control /ft ! ft '
❑Geothermal(Closed Loop) dTracer C20:DRII;'LING'I:OG;(dttacl additionaFsLeitiifnecessary-)i
'FROM TO DESCRIPTION(color,hardness,soil/reek type,grain she,ete.) -
• OGeothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) �ft r' r:' ft. o -
Date Well Started '3 -- L a ©,
4.Date.Wr11(s)Completed: - /Z`2 04 Well DM. 4-Pa•7 41/ '9 5 ft. )0 ft -Vtil ' rf'O-j`1- pf:^n✓G>; (c>/
;'t.e l. "ca,•
Phone#: 503-Ai'?o.''fl'i 2 2& 5-eO ft hw�:''dt✓'i`- r00�.Sa Well Location:. - v1
:' ��� ra I ft. 415 ft. 1.1 j1; : racti- - haeJ. root. .
s?",.r �V Facility (ifapplicable) 71 S � I `1;. deAr(f--u• #— cr0.14 Facility/Owner Name;'` Facili )IJ# licableft •v
''I •
;0:kil ;• i'eP)6 4le , 6I',e..c, :4,��U ttt�,jr.4!//�@�y f ft..
'.. if -
Physical Address;City,end Zip / �C11 ; • 3 '. a..•^r• o f,
/ y G21:,REIl3AIZI{sw:_- -:Y-« - r.»'.
ire,A� • .al'RJ 0 1014.
ti ,County . •. Parcel Identification No,(PIN)
r , ;Sb Latitude and longitude in degrees/minutes/seconds or decimal degrees: " s=, 1 S"''.' y i'9 - •
1 (if iveil field,one let/lona is sufficient) 22.CertIfica' - DIN('t', UC?
i .--:;',‘:: '1'.
j '.
�, ! y 44 N 5.) 1/AA ✓4 51 W :,- )- )-�
' ;'6:IS are the well s: ermanent or ❑Teri or Signature of Certified Well Contractor
? `.rI ,. P azY
ci' -`�-' '( " ) -O By signing this fonn,I hereby certrfy that the well(s)was(were)constructed in accordance with, '
i ,7 Is this a repair.to an existing well: OXes or �To ISA NCAC 02C.0I 00 or ISO NCAC 02C:0200 Well Construction Standards and that a:copy,'
ofthis record has been provided to the well owner.
.t+ vh IJthis is a repav;•fi11 out known well construction information and explain the nature of the p _
repay 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:.... ,
constmctioa,only 1 W-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessa ..
drilled: ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ty , (ft) Submit this GW-1 within 30 days of well completion per the fallowing:
t+�%; ram- For multiple wells list all depths different(example-3Q200'and 2®100') p.
: : if ( ).Static water level below top of casing: d.7 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
• '.Ifwatet•level is above casing,use"+" ..-
11.Borehole diameter: 67 24b.For Injection Wells:Copy to DWR,Underground Injection Control(XUC)
4.23
(in.)$11 Off: r�Q Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: V D /-1-1/(7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (33
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
r Permit Program,1611 MSC,Raleigh,NC 27699-1611 .•.
13a.Yield(gpm) a A Method of test: �I Date Site Visited: p � 3 ~
o
13b.Disinfection type: 7��° hth Amount: '4 s e '+ 1 OZ Site Visited By: v I� I
Foint_GW 1 __ ..-- v"at..c....u—no - i ant of•Environmental Quality-Division of Water Resources Revised 6-6-2018
' •