GW1--05552_Well Construction - GW1_20240913

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AVELL CONSTRUCTION RECORD (GW-1' For Internal Use Only: '
1.Well n tar Infor 'fion 3-4
.11,c /iS 14.WAI 2`7ANES`tas;l., ..0 'ti
t FROM TO DESCRIPTION
Well Contract • 19(6 ft -ci oftIt
6
� ft ;- rt 1. I (�
NC Well Contractor Certification Number
Yadkin Well Company, Inc. €:is:'out:cnsnvG(fo= r1 "eedwe� oRzMvEl;;iii iira,;aPS;: :_ 3
FROM TO DIAMETER. TEaaRNESS MATERIAL
Company Name �• ft. A it. •F..0.5. in. 50�- @ fi�i�
y® 16r�Il1NERIC9SING'OR;TECIDIT :(aeotliermaralos�aloop)=`."::;I;Lii::1-"--..
2.Well Construction Permit#:#` FROM TO • , DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc) ft. ft ' in.
3.Well Use(check well use): ft ft in. ``'
Water Supply Well: d L7CI?EE1�7sc:,.....u ':r;_i3 is ::-,a ::';t '» _`.
FROM TO DIAMETER SLOT Sr%3+-• THICKNESS MATERIAL,
Agricultural ❑Municipal/Public ft. ft. in., "..f----.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industiial/Commercial ❑Residential Water Supply(shared) vaRm .:.,,.,,.;..,.• • ,.••-- _- ----
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
a
Non-Water Supply Well: 0 ft -2...Ult. IN ,a fati.r c c
❑Monitoring ❑Recovery it. ft
Injection Well:
ft. ft •
❑Aquifer Recharge .OGroundwater Remediation l.r19SAND/R& EIPACle(ifr beaI l:•: '*"..4-"..::7,- `:i',__:v
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❑Agnifer Storage and Recovery ❑Salimt Barrier
FROM TO MATERIAL EMPLACZMENTMETHOD
DAquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 1;•20:'DRIItINGZOa(itthcli additi'o"nil'slieete'if:necessa£•y):;,=: ; sat:;: .;`•:"::'
FROM TO❑Geothermal(Heating/Ooo�gRe 3 .Other(explain under#21Remarks) 0 ft 51 ft � N(COtor,hudness,sotllracictype grin etc.)
Date Well Started % ✓� �(, °
4.Date Well(s)•Completed: `� '�Z_/1 Well IDi9 , 04'15 g� 34 ft. •,O ft. 1A/8 4,;,j'.4,��' {� �ck .
5a WeIlLocation: Phone#: 3 s�- Et*, 7(® //c' i ft b 1i it pep' �• ,� 7`- — �� ) '
rA;ft \�'"rin ' t3 ft l oo it• �;y:.,*4-e., ' S••P L:.. �/ S"•i 1
Facility/OwnerName , Facility ID#(if applicable) ft SEP
n •i
�' �kit l �A s � ft. it" J r S 2024
Physical Address,City,,and Zip an alai
ft. ft l f,:.:".e.ult- ?r.-.r .
�1 C� 'r !.1 A '
f o e^ gyp p :21`]RF.BraIR* S :i -, lam' v t4-4 a 7,,.,. -,r
County Parcel Identification No.(PIN) .
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5b.Latitude and longitude in degrees/minutes/seconds or dertmal degrees: /. '' ' • .
(if well field,one lat/lorig is sufficient) ® a 22." tification:
• 76. At) I� N ir/c O ®C27 W .. .1./ '6.-2, 6
6.Is(are)the well(s): OPermanent or ❑Temporary sgn, e.fC �edwellContractor Date
•igning,its form,I hereby certrfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l]No 1 A N 02C.0100 or I5A 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 thisc
ord has been provided to the well owner.
repair under#21 remarla section or on the back ofthis form. vvvv
23.Site diagram or additional well details: -
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
_construction,only 1 GW-1 i)needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 9 '24.S uiiMITrAL INSTRUCTIONS `
9.Total well depth land surface: P2® (ft.) Submit this GW-1 within•30 days'of well completion per the following:
For multiple wells list all11 depths if diiferent(example-3Q200'and 2Q100)
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24a. For All Wells: Original fox to Division of Water Resources (DWR),
10.Static wafer level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" Q�( .
11.Borehole diameter: (in.)Bit Off: mS t 1 69( .24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AP ice 4-cify 24c.For Water SSupply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 2
13a Yield(gpm) Method of test:_ a.4' Permit Program,1611 MSC,Raleigh,NC 27699-1611
o Date Site Visited: q—1 cd'2: �m o
70/o hth • i oZ Site Visited By: 0TE.13b.Disinfection type: Amount: ( �`c
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North Carolina Department of Environmental
Form GW-1 __ Quality-Division of Water Resources j Revised 6-6-2018 ieg
Price: = ._