GW1--05588_Well Construction - GW1_20240913

74,T,CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well ntractor Informaatioon� J
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FROM TO DESCRIPTION
Well Contractor Name • ft nifcg
ft .‘ LA
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NC Well Contractor Certification Number :1•5:'OUTEFMS'IN� :(f rtailiiRiiee3':RS R'T.i1P,jES;i(ifsp`licalikS'-L . n �
. Yadkin Well Company, Inc. FROM To ,DIAMETER TffiCENESs1 MATERIAL
ft I ft. c 12 S' `Sn. o •-G A c
Company Name � '� 2- - �� (6T" t`'i::`.,-.
I s r16sIl`INEROASING:012�IIB1NG: eotlieimitl'closedluo�='• "=.akli
2.WellConstructionPermit#: P (e�0 1 FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.(1IC;Cowtty,State,Variance,etc) ft. ft. in. ��
3.Well Use(check well use): ft. ft in. -i
c:.r:X.c .. ..... .. -._.,"_:if =':: is..`.-.. `;b.... :.,zit-..," .-...�,,,1..
Wa -r Supply Well: FROM TO DMA ETER, SLOT SIZE , THICKNESS 9 MATERIAL
r•z:cultural ❑Municipal/Pablic ft, . ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in. .
Pv-
❑Industrial/Commercial ❑Residential Water Supply(shared) _ ,""r _ .--n
:'S18.a,GItObT"'; i= , ..'sa i.r I'irJ:_J+: :�7 t "
❑Irrigation ❑Wells>100,000 GPD FROM TO /M MATERIAL EMFLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft 1��/"�11.f {Q A� �.�I�O(
• ❑Monitoring ❑Recovery ft. ft I
Injection Well: ft. ft. F44°.
❑Aquifer Recharge .❑Groundwater Remediation -
ii19..SAlli/G12 AtI?tieilpll.Mrej' "•`,::, ;;Z: ..'._':i: :7::;.2,
❑Aquifer Storage and Recovery ❑SalimityBarrier FROM TO MATERIAL` EMPLACEMENT METHOD ' •
❑Aquifer Test ❑StormwateiDrainage ft ft. .
❑Experimental Technology ❑Subsidence Control ft ft.
DGeotheriàal Closed Loop) OTracer iaOiDRI BCs,TZOG'(ittikli-addiii'ona�"sIiietiiifnecesseiW;i:_r_ i; 'cYS i iP.:t
❑Geothemurl(Iieating/C oo g Re ) 4Other(explain under#21 Remarks) -FROM TO' DESCRIPTION(color,hardness,salllroek type grain size,eta)
Date Well Started U 2 -'� . . .0 ft 0 ft Of r,f
4.Date Well(s)Completed:()7 .14 v2 Li Well ID#P " I WY. 7 I ft q U ft ` a fi dia.' f"
Phone#:7,it- fe$'t�J'° 2 S'4(di \ 11 ft CO‘ �' Q ®t
5a.Well Location: () {� i
,akua TiAliA5 or\ 11 ( f• !Z IL g ut li$ • ,-' -• . i,• f,^-..
Facility/OtvnetNanle Facility ID#(if applicable) ' I Z 7 f /1_ t. (q.t 1'�'"•'
•
;I SEPl :�� 2024 Q,
Physical Address,City,and Zip OC 106 e1 •cf2I ft. ft ..
/j� L IF:.v:'r��tira.�7. 1
Eg.
County - Parcel ldrntification No.(PIN) - '
. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one latllon'gis sufficient) 22. ' :'cation: - '
2.eo k N �, 6 C C7 w ill p L
Z4.
S:.a. 0 fr
lf ed Well Contractor C .. Date'
6.Is(are)the well(s): ermanent or OTemporary
4v s ling:• fans,I hereby Celli),that the well(s)teas(were)constiucled m accordance with Q�
7•Is this a repair to an existing well: ❑Yes or &it 1. NCAC 02C.0100 or ISANCAC 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. R.
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
COonstmction, nly 1 GW-1 is needed. Indicate TOTALNUMBFR of wells (add'See Over'in Remarks Box).You may also attach additional pages Accessary.
drilled: / v 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 3 t. (ft.) ' -=
For multiple wells list all depths if different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
24a. For Al] Wells: Original form to Division of-Water Resources (DWR),
10.Static water level below top of casing: . t (ft) Information Processing Unit 1617,MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
„ ! 24b.For Injection Wells:Copy to DWR,Underground_Injection Control(IUC) Or11.Borehole diameter: 6 (iu•)Bit Off: tI• Program,1636 MSC,Raleigh,NC 27699-1636 z
12.Well construction method: OU r y .)4 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
�n ,� Permit Program,1611 MSC,Raleigh NC 27699-1611 �/� L
13a.Yield(gpm) Method of test: 6 t!hr/h y er�Y111 V
o h Date Site Visited: �'�2y !�
70/o th Amount: f 1.. Oz Site Visited By:
. 13b.Disinfection type: S j' g• ii%pen --I-or-v
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Cct Ii l Revised 6-6-2018
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