GW1--03597_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -,
1.Well Contract Information:
itef 1,d y 4 W1;17+R`ZONFS'_
Well Contractor Name FROM TO DESCRIPTION
�S US •
S 5Cr ,ft' - S f&t (c7 G?N) (ice- �`
ft
NC Well Contractor Certification Number : (fo •
WO1711 GilSING �nllt,sed:welIs�'DICM'Fgre.i" lkf•::, .::... .. 3
Yadkin Well Company, Inc. PROM _TO DIAMETER THICKNESS 1 MATERIAL
ft ft. in. P
Company NamealI,�ryr Q
2.Well Contraction Permit#: P AWL 2.0 V SO I PR_A�IIVE1t+GASIPIG'OR ITl:5tliermalclo"CENEop)"
List all applicable well construction permits(i.e.UIC Cownty,State,Variance,et. PROM f. TO � ft_• DIAMETER,C+ in. THICKNESS MATERIAL
) +'I to � s •ilq 64v. .5Itt1 L.
3.Well Use(check well use): ft. it in.
CA
Water Supply Well: i37:5f3
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultrual ❑MMnnicipalPublic ft ft in. (p
❑Geothermal(Heating/Cooling Supply) C7Residential Water Supply(single) ft, ft . in
❑Industrial/Commercial ❑Residential Water Supply(shared) .
i ail.Gkttlyi 4?:':.:
❑Irrigation ❑Wells>1(l0�0ooGPD PROM TO . . •' MATERIAL EMPLACEMENT METHOD&AMOUN "
Non-Water Supply Well: d ft. 30 ft 01)Chi
C,1 L yrmvl i. , 9 }
OMonitoring ❑Recovery ft. ft '`
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation
j'19.SAND/GIY0Zp.A( (fE,tpplxcab7e) ::`.`
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
❑Aquifer Test CIStormwater Drainage ft ft.
❑Experimental Technology 0 Subsidence Control ft ft.
❑Geothermal(Closed Loop) OTracer .20 DRIL1 iGI OG(atticli i'ddttiol al akeeti if.'rieceis' 4;:,:
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks) FROM TO DFSCItD?TION(color,Lardness,sa0/rulc type grain she,etc.)
Date Well Started S— -a,t4 �Q fit (p� ft. .56"we)
1
4.Date Well(s)Completed: S-'^�)2L\Well ID# AA( — Z c7 }r f5a.Well Location: PhOne#:3„5(Q`-•-C2-J'Fi It ftftpsi. �a�, `�� yZ hrar� bow-�?�a�r��•�-Q
Thiel, S(el n ft. ft
Facility/Owner Name Facility lD#(if applicable) ft ft ^ •' C
3 51- - 144 riouev�L„‘ L-ahi9c,,, Ce ft. 6"--
Physical Address,City,and Zip ftai07% ft ft. JUN 1 N 2024
Coun i�r� ParoelIdenrtificationNo.(PIN) 2 �s"vJf� it cr7r4..i.l '-r y..i:-.; 'Uini
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
r� 22.Certification:
7.�C 0 3-sr-A;�� N oVr '7 r.33711 W i, - _ �v�
C
6.Is(are)the well(s): L ermanent or OTemporary Signature e ed Well Contractor Date
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ME( ISA NCAC 02C.0100 or ISA 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
constmction,only 1 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 de th below land surface: (�°
For multiple wells list all depths ifdifferent(example-3®200'and 2(a3100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: / (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: `p (In.)Blt Off: S 7S5LP
. 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC) .-- t
Program,1636 MSC,Raleigh,NC 27699-1636 ..........
12.Well construction method: i'.�., i 4 ''2` >,f�� 24c.For Watersupplyn _ re
(i.e.anger,rotary,cable,direct push,etc.) county environmental health department f the county where installer Copy to the -p
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2se Method of test:
i r-- Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth 2 Z oZ Date Site Visited: .S-27—V/
13b.Disinfection type: Amount: `,) Site Visited By: 0 71.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: /9 2a J. -7 a