GW1--05557_Well Construction - GW1_20240913

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i WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
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" 1.Well Contractor Information: P
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1 4-4 e i11, . re tA,/It raj'WATEItZONESt:=:_::: i I
WellConrtractorName FROM TO DFSCRIPTION
�.5 •
6 /6 00 /7o dt 7 1 r •
ft ' ft
I 3`6
NC Well Contractor Certification Number
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c 15.'OU11Wh..ASA`I• -Vrir'miilti a erl iellssTORxaVF�12;(ifaji l •7 `
iMilif LiY: ," .
Yadkin Well Company, Inc. FROM TO _DIAMETERM/i. �S MATERIAL 4-9
Company Name
aVy,'® ;:r ��//
'E �G�R Tf7BIIlIG_(eottifrerairiedloopo',i: •;..i�.�•..
2.Well Construction Permit#: FROM TO Dom..:_. A SS MATERIAL
List an applicable well construction permits(i.e.viaCounty,State,Variance,eta) fr. ft in' /i
3.Well Use(check well use): ft ft f;.;in
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Water Supply '39::5'. >;'. .--: Q1113.:.'t:,. _ 314:_`�::r-'^ ^ �,•_. ,
FROM TO. DIAMETER SLOT SIZE TRIMNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft• ft in.
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) fr ft/ in.
❑Industrial/Commercial ❑Residential Water Supply(shared) •��' - .
i18 rGI2dVP ?t;= 7i•. ,,o .i ....;_ ti 5-:w :': ,'.:.. Bi(�®
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL j �'.EMer,Acm ENTMETHOD&AMOUNT CP
Non-Water Supply Well: ft ,2 2 ft ^ wsi-e. Co/p S 6 rca,l
47 ha-1
:Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
f19
DAquifer Storage and Recovery ❑Salmi rBarrier :SAND/2 Vgaa" tYtiitPipplicable) .ts; :'i: ,,, ,,,,,,._.Y,_� .
FROM TO MATERIAL EMPLACEIvffiVTMETHODF •
DAquifer Test ❑Stormwatei Drainage
❑Experimental Technology CI Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer le10DRIU,°LIVGI:OG(iitfac2ifi•0ditioniTslre`efe'if.'ue'cnsafy)=,._ ;,...-e�1 -,S .�_
• FROM❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) To DESCRIPTION(color,hardness,soil/rock type,grin size,err
Date Well Started /6
ft SO// .If- 40.4:1 rave.if 12, . ra
4.Date Well(s)Completed:7_ichkac/ Weu 46_ 72. IC ft repft q'Q/r�C�i 1 ��
5a.Well Location: Phone#:`�p e,,—.1/— d 3z 7 m-svft i 70s-ft ..5 rrm 4;.e., r
a ' ft -�.
/�� L,J ,` l f • e7o.3�s• lei / ;f,4 :•:. 6; ; :r.77,-�.;�• _
Fae• /Owner Name Facility lD#(if applicable) ft. \ - ' r�-a+.!L t1 o....L
5
ft • �* "124
Physical
®Address,City,and Zip ,2 6°iZ s9 tt ft
_ / i 1 y, .s+:_ :`�r• .F.$-ram 6
County Parcel Identification No.(PIN) p �e ed 4 o •1' /kee 474f �'f3 a r;�
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: a yd 1 i'/-, CO !".:.,'-j3P a,.
(dwell field,one latllong is sufficient) �t 0 B' •F e et'• `/3fea
�` • 22.Certification: '7
• 36a /377/ N a- , gulf7 WA4407-, ,,,/,' ,&,, "a
6.Is(are)the well(s): 'ermanent or OTemporary Signature of Certified Well Contractor Date
By signing thisforn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ( To 15ANC4C 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 aidexplain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional weIl;detaiIs:
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 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: \ �r 'e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 4Y R Submit this GW-1 within 30 days of well completion
Far multiple wells list all depths ifd8erent(example-3(200'and 2Q100) ( ) y per the following:
10.Static water level below top of casing: 40 ? , , 24a, For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"i•"
1,1.BorehoIe diameter: 6 (m°)Bit Off: S,On 24b.For Injection Wells:Copy to DWR,Underground Injection-Control(IUC)
a Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: drd'P re)ler r y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the Iii
(i.e.auger,rotary,cable,direct push,etc.) ® county environmental health department of the county where installed
FOR WATER SUPPLY'WELLS ONLY: • Z.
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Met
1 ►(ifhod Permit Program,1611 MSC,Raleigh,'NC 27699-1611
of test: ol✓q�
70% hth Date Site Visited: —2 e 2/- -2 V
13b.Disinfection type: Amount: OZ Site Visited By:
1 0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 6-6-2018 ®�
Price: No.
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