GW1--06160_Well Construction - GW1_20241014

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"L CONSTRUCTION RECORD (G®W-1I For Internal Use Only:
1.Well Contractor Information:Y0�t W 1 lI(XP'1 (1(AIi S e)-r AT zolvEs w�
Well Contractor�ame • ^FROM9` TO ' DESCRIPTION (to
66 -A 1 60f. ft. I. 5I. I V'
ft ft I
NC Well Contractor Certification Number 1-5,OII1 :CASING`(fui�Tula:ca'�aded'irelePaRTiIL�TFJIii(if.$P liea')e)r . .. l�/_
• Yadkin Well Company, Inc. • FROM TO ' ,DIAMETER. TffiM4ESS MATERIAL
CompanyName + , ft. q El ft 6. 1 2y in- sbp-ir` Pvt_
�(�9 ii16r�INKR.CASANG:OR.!atilNG=(ge"otlir malrlo9 cTited7�..-..,.:,": :;.i;,":z
2.Well Construction Permit#:0 a 0 Cn 7 ` 2 o �SL FROM TO . DIAMETER THICKNESS .�MATERI L
List all applicable well construction permits(i.e.UIC,Comrty,State,Variance,etc.) ft. ft• ' in-0/
' 3.Well Use(check well use): ft. It in.
Water Su I Wall J:7.'SCRE4t.::r°:s v:._i'w' :7 t_.:n.::E,2:71 :`;• '.: '.,.-...�i.8'�=:_.,r_, ,.''' y "
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL F�`��,
['Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) :-.• -• " , _. ._ `
18�GECOUT.`5`>a�'"ix °sir:` i :?.:" ice:+,` :r.
❑lrrigation ❑Wells>100,000 GPD FROM TO nnMATERIAL •EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2-v ft GeAe N Gil;0 S P u
['Monitoring ['Recovery - ft ft.
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation
i 19.:SANDIGBA,V. I2-Y:•Millap`plicab54_:., .:,.": . ;i;:'•:i•<: ,; >'a..�:.••n,:.. _
['Aquifer Storage and Recovery • ❑SalinityBatrier • FROM TO MATERIAL �EMPLACEMENTMETHOD •
DAquifer Test, ❑Stomnwater Drainage' : ft. ft
❑Experimental Technology ❑Subsidence Control - ft. ft.
['Geothermal(Closed Loop) ['Tracer c%20:DRIEtINGIAG.(attsiclisiiditigiiiTslieetiifnecl'iiiFy 117 ,'6.r2
['Geothermal(Heating/C..'.g Rgml, "Daher(explain under#21 Remarks) FROM TO DESCRIPTION(color,hazdness,soil/xnek type grain site,ere)
Date Well Started 6 ` `0P 4..� ��( d ' i S ' 6�&C-k trj 1.-4- ©l'I" r_
4.Date Well(s)Completed:o q o 0 6-2 4 Well ID# • 1 I ft. 16, ft ri d . .
5a Well Location 'Cs "" 7-7 ft 9 4 ft r r6,1
-4vaar.cat Oret-eje. 0 ter 9 S ft' �(0 ft �"/�1l ea ��G:. ��.,
Facility/OwnerName Facthty #(if applicable) ft. ft r �"`"^ •..-'' ,` a,' ,.:.'a'•'' ..
/+n // y� •
`�/� /� lac.:. ,
f c 2 /lit( ev e e kC4. c@)J.&A . IsIC ft. ft 1'r r 1 /n�,,
® � ft ft. j L U
Physical Address,City,andZip VI ,
ARYCfi-' :-cr -t?:,:,,c•.•;i 2g4ri+:,3a= ih4;h:7,
County ParcelIdentifi cation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds'or derim el degrees: a.
(if well field,one lat/long is sufficient) 2 ertification: 9
c��- ir N go, 9�e Rr I . • ✓ -i 4' _ 6 1-`6.f+j-2 .
6.Is(are)thewell(s): permanent or ❑Temporary
'.�_.=.Lure of C • d Well Contractor 1i Date
By signing thisform,Thereby certify that the well(s)was(were)constructed to accordance with
7.Is this a repair to an emasting well: DYes or &ea 1SA NCAC 02C.0100 or ISA NCAC 0?C.0200 Well Construction Standards and that a ropy
If this is a repair,fill 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
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 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 ` O, (t) Submit this GW-1 within 30 days of well completion per the following: •
For multiple wells list all depths if different(example-3Q2000,'�and 2@1001
10.Static water level below topof casing: ` ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
g Information Processing Unit,1617i MSC,Raleigh,NC 27699-1617 ,,,�
If water level is above casing,use"+" i
11.Borehole diameter: ‘ (m)Bit Off: S S. 9 3 S 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)
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Program,1636 MSC,Raleigh,Ng 27699-1636 es
12.Well construction method: Al, 12,J-Ar 24c.For Water.Supply and Open-Loop Geothermal Return Wells:Copy to the a)
(i.e.auger;rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/s Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I t S Method of test: IA 1
o •
Date Site Visited: 1 -a c/
13b.Disinfection type: 70�o hth Amount: 1 6 OZ Site Visited By: 017J i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: !c- a. .S-, 74 J