GW1--02342_Well Construction - GW1_20240410

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-.---- CONSTRUCTION RECORD (GW-1) • .• For Internal Use Only: < •
1.,We1I Co tractor Information:il
LAJ/1 (14i'.WATN0ZONESI Z :itil-T!VI nl'il'i-�:'•d»..ili':�i,''.ti' .a.;�1.7.i r 17..a rn .
FROM TO DESCRIPTION
Well Contractor Name -is-ft. Tc ft
210 fL a1.- ft.- Gvl ,' 336-317_ to-0,,
NC Well Contractor CertificationNumber 8'15::OUTERVASING(foniiilti=casedwellss):O1CLINEXt(ifap"licaltle)'F==::%L,:>D
Yadkin Well Company, Inc. FROM TO DIAMETERi' THICKNESS MATERIAL/. -
•CompanyName I ft in. f�'' y /'
yp A pn a� ► I. 16r1NNKfCCASING:OR:TUIUNG:(ge'titHeimaYellied:liicP) -t- i,1:
2.Well Construction Permit#: C§ U a �`A/ L `d '11 FROM TO DIAMETER I THICKNESS MATERIAL.
List all applicable well construction permits(Le.U1C County,.Staie,Variance,etc.) + 4 ft (�/ it Q , Irn- 3c4 d10 CAlt j- +ee, i1In
3.Well Use(check well use): ft it �9• lin 4015- �- Y�J .
Water Supply Well: raj SCRE$7f_.= ='-""'•--=-__-_-___-_�_ ._ -7
PP yFROM TO_ DIAMETER; I SLOT SIZE _THICKNESS MATERIAL __
• ❑A.gdcultu al E Municipal/Public ft ft I'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft I ���
❑lndustrial/Commercial . ❑Residential Water Supply(shared) ;._18:GRobTt----,5�---"----" ,-'"7--.--EMPLACEMENT
-`. ----- -_`-`.` _
❑Irrigation ❑Wells>100,OdO GPD • FROM TO MATERIAL: EMPLACEM TMETHOD&AMOUNT~
Non-Water Supply Well: . ' 0 ft.
6 it � ¢ e,�4.t¢ PL°at a9 I
❑Monitoring ❑Recovery ft. 43 ft I
Injection Well: fr 1
❑Aquifer Recharge •
.0 Groundwater Remediation •` • ,__ �- _
't'_19,.SAND/GRAVF.I''rPAC.it(rf spplieiible�':` - r'•
❑Aquifer Storage and Recovery ❑Salinity Barrier • FROM TO -...- MATERIAL. -EMPLACEMENT METHOD ' •
DAquifer Test ❑StormwaterDrainage fr• ft
❑Experimental Technology ❑Subsidence Control ft. ft
-
OGeothermal(Closed Loop) ❑Tracer G20:DRIf IPIG'I:OG'(attn'chit]ditianaI`sheetiffnecessarg)' 1__-_. _�r._�
FROM• •TO DESCRIPTION(color,hardness;soil/rock type;grain size,etc.)
❑Geothermal(Heating/CoolingRetum) ❑Other(explainunder#21Rernarks) ft Cl�
Date Well Started o all ®/ d
4.Date Well(s)Completed: @ . 4s I(Well ID#A/P/ ..-179 ft. ® ft. . J ern n /C,,
•
5a.Well Location: r J Phone#:33C,-' r/4-3,3 o ft. 3G2. ft "IfQIsiPr -
eJLhD� S e . 9(4 1 f�,t fr. ft. ,, .- c
Facility/OwnerName Facility ID#(if applicable)
fL ft. t 1.. ,C c.-,1,-- t' 7.-�l
7 711?-. SY / /�1�L ✓' ft. ft APR 1 -+ij' 2024 -
119G11 .1'C,�.�v ` .S�i�_&.�(�j�a9 ft ft.
Physical• 'Address,City,and Zip : I '' •_- t a
Cobalt MA'K,S::.-,-•.:=7.2. -7117 ice: �'i..il::'. _2.?.. ..__ _,3
e i •
Gr+ 1t"
County Parcel Identification No.(PIN) S'✓
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4'4?5 ,0� &4'1i ame4`MJ`� • %
(if well field,one laUlong is sufficient) 22.Certification: 1
•6.Is(are)the well(s): l/ermanent or ❑Temporary Signature of citified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or < lVo 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 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
construction, ` (add'See Over'in Remarks Box).You may also attach additional pages if necessary. Vl,
on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wellsI '�'"
drilled 24.SUBMITTAL INSTRUCTIONS 0) .
(ft.)
9.Total well depth 6 t£depth below land surface: 1
Submit this GW-1 within 30 days of well completion per the following: M
For multiple wells list all depths if different(example-3(g200'and 2Q100)
e� 24a. For All Wells: Original fo to Division of Water Resources (DWR), .3
10.Static water level below top of casing: ®®.d (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 P
If water level is above casing use"+" /t ®/ ®o
11.Borehole diameter: U (in.)Bit Off: 24b.For Injection'Wells:Copy,to DWR,Underground Injection Control(1UC)
6 U 3'6a' 4 /28 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24e.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 01
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
{9 i Permit Program,1611 MSC,Raleigh,NC 27699-161]
13a.Yield(gpm) / 70-/icply Method of test: I,sj tit/v
o Date Site Visited: S ' 23-2.3
/y
. 13b.Disinfection type: 70�o hth Amount: �/ OZ Site Visited By: Dan '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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Price: ,