GW1--06146_Well Construction - GW1_20241014

°F — ;LL.CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Alt-A. / +4 _Ate tve7 w°a4:;WATER:ZONES r�,-`cdrt:Ts•:-:... I•.1�7.Rtin ,;: -;i,.;:"Li. �z.'2.-..=::2- s FT: irO .
Well Contractor Name FROM TO DESCRIPTION r r
. Y YO ft 200 ft ..�I!, !�r�r- /35&,
NC Well Contxactor Certification Number - fi5;OuT R:CASING:(fdcmultimatediVeIIs)''OR'LINER`(ifap`licable)�`,',`_'_'r. a/��
Yadkin Well Company, Inc. FROM TO • DIAMETER THICKNESS MATERIAL -`
. �r�y ft in �� ..„,.,,...--°'(rV
Company Name 210
1® 6 9
16IlNIIVER•CASING'ORTl7BING," eutliermal:rloeed=loop)v =ti= .:;'
2.Well Construction Permit#: ,oJl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) 44 ft. o f l ft 6,47,E il (d/tiif/# 64x, s
3.Well Use(check well use): ft oY ft !e in �i RA v" T
Water Supply Well: ri S i.4f�-------�•w _'— -,.._ :'=-.___''`-= -�.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Pablic ft r
in.
0 Geothermal(Heating/Cooling Supply) IResideatial Water Supply(single) ft it i .�
❑Industrial/Commercial ❑Residential Water Supply(clmared) :18.IGRODTL' - - :wx:�_ =__ re_
❑Irrigation ❑Wells>100,000 GPD FROM TO Y MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:, '-,: -^ --) ° ft -2/ ft .,u2� a/iI 6_- u1. r /2
❑Monitoring .. -.."�..:• ❑Recovery ft ft. - �4
Injection Well: _
❑Aquifer Recharge O 1.T 1 4 2O24,_,Groundwater Remediation
OA uifer Storage*Recovery :y19 Si1ND/GRAVFL'PACK'(if:applicab)e)''` ' '__. - .
q g ery.,_,_,, �,,:,_O•Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
❑Aquifer Test G :;; OStor mwaterDrainage
❑Experimental Technology - 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) " , ❑Tracer 1:20:DR1);"GAVG`X:oG`(iittach,additinnelsbeetvfnecesv i :-y_:_
❑Geothermal(Heating/Cooling Retain) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,scared(type,grata sing eta)
Date Well Started ". v '> _ ,oft. ft. .4--ft. /
4.Date Well(s)Completed:9- + 'Z well ID#41j'/ -( ft ft
•
5a Well Location: Phone#: Sag- /.'�'.-33 9 i4 �Q' ft 0 ft d i' VO cts.. " .�!l '2 . .
et ta'l 1. • C.® f a � ft' �/Z f l i,5�1Li-yt L .S'04.-- t
Facility/Owner Name:.. ,': 1 "r • Facility ID#(ifapplicable, Z ft )2 0 ft J , / S Y,%�'"(bci- � ..
.. chi' , : �s, H 6'Si_ _321 6 G)vz& IL Lai f. 1,34.1. 160%- kcc. :SAW. _
rt.
Physical Address,
��dress,City add Zip
g ft -
t
County . P• arcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ''
(if well field,one lat/long is sufficient) " -22.Certification:-'.. " - ), .
sag P
ge—....r . 4.:1,--e . I-_- 9- icofE
6.Is(are)the well(s): f�Yhermanent or OTemporary Signature of Certified Well Contractor Date .
By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1`VNo 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy'�,If this is a repair,frll 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 C+
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: I 110 24.SUBMITTAL INSTRUCTIONS
9.Total;Wve11 depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
Far multiple wells list all depths if different(example-3@200'and 2®100)
( 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static-Water level below top of casing: ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
- ewater,level is above casing,use"+"
11 Borehole diameter tp (in,)Bit C ff; $ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well Construction method: le'd f 41 Jr 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the,
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
` s FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
, Permit Program,1611 MSC,Raleigh,NC 27699-1611
o-
13a.Yield(gpm) " Method of test: et/ ' O
70% hth Date Site Visited: .g z 9-2 3
13b.Disinfection type: Amount: 0 OZ Site Visited By: /5 '
•
____PornoGW I_ __._.____-___ _North CarolinaDeonitment of Environmental Quality-Division of Water R ounces J V) Revised6-6-2018 Ilk 111/'
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