GW1--02338_Well Construction - GW1_20240410

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
r , ell i^� 63:4>WATERZONES _ -
,.- +<i3�,' V....- . :?^"• 3^' .1 .5Z:.' :;�' G,.a ;; � .
Well ContractorNaa4e FROM TO DESCRIPTION �t9 I
®i�„ft. // aft 8�d+��lei
Sr ,4 ft. ft
NC Well Contractor Certification Number f1S..OUTEACCASING(fo 'multi=easedNwells):ORLIVER(if.'aphealile)'l'' Pr'`fi0
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL _
ft ft I in. ®+
Company Name _,ro v...:,
3 .y '16:1,EDERCASING:OR.T[IBING(ge itliermal"closed:loop) v^ `:a:,: ;cy
2.WellConstructionPermit#: d FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) 4 I ft- r-- ft- 6 a/) ,14)/2 ?d am P
3.Well Use(check well use): • ft. �7 ft in.
Water Supply Well: Z.17.?SCR ., .sr -,;,, r' , _"',.: :--,'.-
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) -Xesidential Water Supply(single) ft ft in..
❑Industrial/Commeroial ❑Residential Water Supply(shared) ;F187.GROUT=" '` ::a:" '?v:,r<7:'—
❑Irrigation ❑Wells>100,000GPI) FROM TO MATERIALi EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. ei, ft /, ( p� a n,u9fe
❑Monitoring ❑Recovery // ft. s ft Be ,m
Injection Well: ft. ft.
❑Aquifer Recharge ,❑Groundwater Remediation _ -
i)I9 SA W/GRAVE EACK?(if applicable)u :a _. .__ .w i
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL' EMPLACEMENT METHOD r • '
DAquifer Test ❑StomawaterDrainage ft. ft.
❑Experimental Technology ICSuitsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer .7r20iDRIfatiNGLOG°(3ttreh ndditional:sbeeti if necessary)=,._—.=—7173
(Geothermal(Heating/Cooling R,tum) ['Other(explain under#21 Remarks) -FROM TO n DESCRIPTION(color,hardness,sallltack type,grain size,etc.)
Date Well Started a v a 1 .. .® ft. i,:7 ft 3 -:
•.4.Date Well(s)Completed: q � ,frii. ' e f Well ID#AAP m '75 ; e'7 ft. b Qdt eel/lard.ve, ;, 1tiibo s
5a.Well Location: Phone#: sty 32� ®�7a., ft ft tJ�-41 o�
c...1)4 A -% Jr bc1r6� - J6,r"6row`SII&i .. , ft ft. . 1.-.7;! "",''%v- ,n _
•
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft .. r L .i t�..,„
`�l..ct 1r,,1 ,„,. pe i..f`)JC#, � ft. ft. APR 1 0-00?4
Physical Address,City,and Zip �' _
A cS�1 1..:ar MARTts fe. ,s=c. .. ' (~- e� ,e_V... 3't'..®........a
Rr , '��,4ra.0 ,..K
County . •` Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one m t/long is sufficient) 22.Certification:
3� 9( r 29'N $I`� 622' ill" W ,/-- l )-va.41�Y�
6.Is(are)the well(s): 'ermanent or ❑Temporary Si& of vied Well Contractor i Date j
By signing this form,I hereby certify that thewell(s)was(were)constructed in accordance with
` 7.Is this a repair to an existing well: ❑Yes or �No ISA NCAC 02C.0100 or 1SA 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.
i repair under#21 remarks section or on the back of this farm.
;. 23.Site diagram or additional well details:
i, You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop'Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary. °
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
dulled: . -` 6 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - &0 0. (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(ermmple-3Q200'and 2©100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" -
11.Borehole diameter: 6 (In.)Bit Off: 6 a i'e'p 24b.For Injection Wells: Copy to 1DWIt,Underground Injection Control(TUC) , ,„,
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A t 1' - 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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
y..t- • Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: r/� C.t r
Date Site Visited: Z_1'7'la(31
,� \O
13b.Disinfection type: 70% hth Amount: �n�OZ Site Visited By: Aotol 01
l ,
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: St,i, Cet°.+r c.+ 7 f'