GW1--06062_Well Construction - GW1_20241011

WELL CONSTRUCTION RECORD(G9P-1) For Internal Use Only:
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1.Well Contractor Information: j ; (®
1s-4�.WATEVZONEs rIIZ... ;1.:I: ; .- .,..a,,•.,.: • .
We1lConhaetoiName. •
PROM TOp DESCRIPTION
a.Ii ,,p ),
MS W 5--J 00 f t 11a f t c" °r 1� o ® e,
350ft 3 0 ft -1,-Y,cm„.tc. •to G?lei 1 ems lit/ `
NC Well Contractor Certification Number
":1�''oUTE)�:C':/isnvG`(foi�muItcased"weIIs)`:ORT�IERi(ifa�"lice]'e)13:in•X...
Yadkin Well Company, Inc. FROM • TO DIAMETER THiCIcN SS MATERIAL _
ft. ft in.
Company Name 156ffil1FRICASING2OR:fUBIN G(etimlcloe3lap :: s_.
,._r,`•'a _•:"S
2.Well Constriction Permit#: 63i Cr �+ FROM TO DIAMETER TRIMNESS MATERIAL cgtr
List all applicable well construction permits(I.e.UIC,Coun)),State,Variance,etc.) 41 ft 'q 1-1 ft Ce m- 0 Card€.".�'-e e ( i"-
• 3.Well Use(check well use): ft. (p 9 ft in. ��t `�
Water Supply Well: s17::SC k ' '.' :." s F:ai::_c ...:r•.«--- ,.: V�
BROM TO DIAMETER SLOT cMP THICKNESS MATERIAL
OAgricultural ifenn.
iripallPublic ft ft in. .
. ❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
!. ❑lndustrial/Commercial ❑Residential Water Supply(shar zr :�:�•f.•M.• { . • _ •
r18.GROUTf;<,,s:s sn-: .r` ':i•'L^... _ .,.•,•-7 ,.
❑luigation ❑Wells>100,000 GPD FROM TO MATQL EMPI,A METHOD&AMOUNT
Non-Water Supply Well: - 110 ft. ft tri ?Wilk) j6 a}c.l`V
�
❑Monitoring ❑Recovery . ft. ft
Injection Well:
ft ft
'' ❑Aquifer Recharge ❑Groundwater Remediation
•
❑A uifer Storage and ❑Salmi Barrier' i g / P JSt(i ' � ^�`::fs:: >; ,_
q g Recovery ty ,MATERIAL yEMPLACEMENTMETHODy
' ❑Aquifer Test • ❑Stormwater Drainage ft, ' ft
• ❑Experimental Technology OSubsidence Control ft. ft. '
OGeothermal(Closed Loop) OTracer 10 DRI EINGI:OG(iit6idli liddltinnal'slieeti ti:rieceis'i-r'y)'; %;i':. 4`12 x5 1.
FROM TO DESCRD?'IION(color,hardness,son/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 621 Remarks)
Date Well Started 9'-5- ft 0 - (� ft-• .00I `
4.Date Well(s)Completed: 9 ,,, . Well.ID#/ 'bl ®129 IQ 4 ft. 349 ft f} ties,A 71f=fg..
5a.Well Location: Phone#:7:0-22.6.-*2t 3t1 q f' 7 9A ft j3�1th `�>,� grof)
�+ p �./d 1. rFa,�,v,� 792.E 1oCi ft f�Ze'KS�YJ�' i.4e
6-'91>''ei�.4-or dot II gook Q-rrt � r,.si`��'� �'� ft. ft
Facility/OwnerName FacilitylD#(if applicab1)" r_ rt
•
Qi ll1ook a,RA 1300r1.dd9'L'")MC MAGI ft ft. . p .
Physical Address,City,andZip - ft. ft %(�
:21E1)'.l1'rbRxs _ __- ;:-a-,^-cc:.:C=2r`•-.: r_�` .i=_4�t-.}.Y_rfi ,-p_e= x.f __�--
County Parcel Identification No.(PIN) f-
Vc
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C'1 U,-. i 7•:' 'y ' . 1'
I (if well field,one lat/long is sufficient) 22.Certification: ,�
Z(6.. � l i0T ' N 79,.�-2.3- ' w / 1'13-al 4.3
. .• 6.Is(are)the well(s):Di ermanent or OTemporary Si lure o ed Well ontca6for Date
�p By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or r41V o ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
!phis is a repair,fill out known well construction itformation and explaizi the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or an the bock of this form. �i
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
constriction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rrmnrlrc Box).You may also attach additional pages if necessary.
drilled: 'i
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I 0 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diferent(example-3 a@200'and 411000 •
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below tap of casing: (ft) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing use"+„
11.Borehole diameter_ (in.)$It Off: 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
•
12.Well construction method: Al✓1 4544If 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
13a.Yield(gpm) C Method of test: t\ird Permit Program,1611 MSC,Raleigh;NC 27699-1611 6"
70% hth r Date Site Visited: i
13b.Disinfection type: Amount: u ® OZ Site Visited By: i i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: