GW1--06161_Well Construction - GW1_20241014

WEIL CONSTRUCTION RECORD (GW 11 For Internal Use Only:
•, 1.'Wall Contractor Information: ` •
tJ 6: /(t 1 11,Pc, •M. i1s 3.-f ai:wA FZONE.S: ; i. r: ,..I.,-.:
FROM TO DESCRIPTION
Well Contractor Name ap ft e1 Z it Q M
`P • C ft ;• ft V +ice' F'
NC Well Contractor Certification Number i:1i'OIISZR:QASRW(for`:mnIii`:case3isrelLii'vj'DRIZNER'(ifapli eSz r...• 9-
Yadkin Well Company, Inc. FROM TO DIAMETER , THICKNESS MATERIAL.
• ft ft in.
CompsnyName �:: .. - q a
ryry r� (' �7.6".:II�7NLtR:(:9SING:OR�4BING:`(gedtliermaT'clo'sti�:IodP�':,� z ,;nrw�:.�•._ `��
2.Well Construction Permit#: 0 2 OA3/- 2 0 2 T FROM TO DIAMETER TIIIODE SS _'MAATERIAL,
List all applicable well construction permits(Le.via Coun),,State.Variance.etc) + I ft' 9 Q ft. U, 12 S "- S D R-2 9 P V C
3.Well Use(check well use): ft. ft in tit.
Water Supply Well: S o�:i`:':-.r„_ltr.41':v:rrK°�,...�::i ':: ... _ L , Y,••:. . �-
DIAMETER SLOT SIZE.r• THICKNESS MATERIAL, �•
DAgiicultural - ❑MunicipalPublic ft. ft In. .s
•DGeothermal(Heating/Cooling Supply) l!tresidential Water Supply(single) ft. ft in. Cn
' Dlndustriai/Commetcial ❑Residential Water Supply(shared) - x. ,, �..., _ n _ �---�'t 1.4� �r.,as -;t.
:xl$..GIt6UT:. i T��!" . " a, w 7�aA.
•
❑hrigation ❑Wells>100,000 GPD FROM TO. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. a ft. aQr e p Q c k ip S (cur
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft -
❑Aquif Recharge .❑GroundwaterRemediation , y _ _
er j 19:SAND%GRA,$4611EACIC(facififi ales".t _ ;4.:=":ril ,.;::" .
a DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD - •
❑Aquifer Test ❑Stolmwater Drainage ft• ft.
❑Experimental Technology OSubsidence Control ft.. ft
❑Geothermal(Closed Loop) ❑Tracer €201DRI $1GTOG:(attac7iiiaditiona111iiitiifnee ifirry�:;isi'_'cx: `-i c.," mutt -
FROM ' TO, _ . DESCRIPTION(calor,hardness,soillrock type,grain size,eta)
• ❑Geothermal(Heating(CRilingRetum) 1fi pOther(explain under#21 Remarks) ft:
Date Well Started° 1 d 6 1=2,"', 3 . S;C)_fL ��K °r TT, (� ,_
4.Date Well(s)Completed:)9-6)-1,9 weu ID#'i"4 -" 2 7 "' S'i ft' .0 7 f -'J t i>2�:.1 -erte 1'-6-c_ ?
5a.Well Location: Phone#: ft ,0 pit- �[ �' }�
ft. ft
� A4 -(. � s-l •% a
Facility/OwnerName .' Facility ID#(if app �) ft- 4 . ('n n T ' 1 ` -• '_
till 12 �' . G� ,r '' 4 it ft f OCT.'. � 2.0i24 •
Physical Address,City,and Zip 01 if
I[ I',= ,+ .. - K.i21a12ri.MA`RYCR''.i a'�.t ... 4...._.i.._:..r... r.Yt::..^'..,T ,�}"" .5 . ...
�l � li,:v.
County Parcel Identification No.(PIN) ('•-,,
v 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
0
(if well field,one lat/long is sufficient) 2 ert fica'on:
• 3G 2012C " N gCoY- 9 � 9 9 " w /1r. •9'' - 3 ' -1
6.Is(are)the well(s): Cer' manent or ❑Temporary S' a of C d Well Contractor '" Date �
• By signing this form,I hereby certj y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or &iQo 154 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown 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 foim. 23.Site diagram or additional well detalIs:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info a
construction,only 1 GW!1 is needed. Indicate TOTALNUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SIIBMTITAL INSTRUCTIONS-
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days,of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2(a)100) }
is
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 "F.-
If water level is above casing,use"+"
r'. (in.)Blt Off: S 1S 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC) �A
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: 41✓/ ti 40i%y 24c.For Water Supply and Open'-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,etc.) county environmental health department of the county where installed
I ,
FOR WATER SUPPLY WELLS ONLY: • ., 24d.For Water Wells pro ducing'over 100,000.6PD: Copy'to DWR,CCPCUA
a- ( rs Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) V Method of test: Ti j pyaemr L.
Date Site Visited: .7-• ) (,
, 13b.Disinfection type: 7d% hth Amount: 1 6 Oz Site Visited By: PCI ' • g 1,-; I A,
1 `lIo-Css-=9'11/
Form GW-1 North Carolina Department ofEnvironnientat Quality-Division of Water Resources 0 Revised 6-6-2018