GW1--03586_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jj/�tY1..S `- lI 4:%M -ZONES_:._.;,,*. ...A"'Well Contractor Name FROM I TO I DESCRIPTION
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NC Well Contractor Certification Number - CD:15:OU R'(AS (foiatulti=cateTiee)Is):ORI�YNFTC,(if.9'11eca61ef-'..
Yadkin Well Company, Inc. FROM TO D Tgie THIS MA7AL -
t. it 7 io.
Company Name 1111 ffff N
' •16YITII R:GAS1NGbR:TQBIN.G.• a itlietiiiii claeed-480).. •
2.Well Construction Permit#: /k 3 [® 7 7 FROM TO . i DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.CRC,County,State,Parlance,etc) I-I ft 1? 6•j`S ..FF�1 r ?' lr.,
3.Well Use(check well use): it. ft in
Water Supply Well: 1a:'Sclii$1...
FROM TO DIAMETER tiLO71ZE T1fI S MA .T
❑Agricultural ❑Municipa])Public ft, (i. in.
❑Geothermal(Heating/Cooling Supply) .esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i:•181'GBD13T•
Tr
❑hrigation Cl Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,73
Non-Water Supply Well: U ft. 22. ft 15 Gh, $ /1*r,l_ / q ma`s
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. &•-•
[Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAV.EUPAMiE fplrcebliy - _.. .. ..,..
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, EMPLA«a I METHOD
[Aquifer Test ❑Stormwater Drainage ft ft f- �.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 2 .DRIMINGL G(attach a ddititiailsheite if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO nFscRIPrION(color,hardness,sat]/rock type grain size,em)
Date Well Started 5'•3 0 ' 2 G ft ` 0 ft. SO/
4.Date Well(s)Completed: 6-3'2 Well ID#e4,4(2" I bd ft. ^i ft d�.1 roc
/ ('0
/�/�5a.WellLocation: Phon[eJ#: yn / 102' 2,311. era ft. et . iet, rat.. oit,i
/ ! j' lei Ytlo�,f1 a�s,re. +-r i�i/�7J7'(,/1 4Gni#, Coo ft. Cc ft. _Sara.VOL t's / �
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Facility/Owner Name Facility ID#(if applicable) C ft 1 eo ft r '►*�i
(;e. 10 Ala ��1.„A. a ,c„„,►,. a2g607 Zoo ft. 9112 ft d�•�- �k h.,(l.
Physical Address,City,and Zip ft. ft.
�� ems/ »,," ...4
r:l 1 At/ L '21iIF•MA II S •h...`.I a__ i,
County ` Parcel Identification No.(PIN) •!IN 1 .c
IV 1 2GZ4
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) IrrtJ:.r.i.i.'t..1 - 'O -
a 22.Certification:
` 6y �/ 3 N © e 3g/ s� /` W %�j • q �/
tJ ti ,r/ "J- 2" t
6.Is(are)the well(s):XPermanent or ❑Temporary Signature o ertified ell 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: ❑Yes or eiKNo 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 remarla•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,only 3/4.GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0.2 (ft.)
For multiple wells list all depths if different(example-3@200'and 22@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: a00 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" q Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C (in.)git Off: �/�Y 24b.For Injection Veils: Copy to DWR,Underground Injection Control(IUC)
11 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a J../ �'/ � I a 17 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 9-2
IPermit Program, MSC,Ra1ei@i NC 27699-1611 -
13a.Yield(gpm) Method of test: Y i et 4 `0�,I ,
70% hth Date Site Visited: ! e
13b.Disinfection type: Amount: OZ Site Visited By: .sIL
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: