GW1--06903_Well Construction - GW1_20241118

•
W aL CONSTRUCTIO—RECORD (GW-1) For Internal Use Only:
-
1.Well Contr•ac r Information:
}�CCO() ti� Pd
r--: .WATERZONES:, , :We11ConLactor ame FROM TO DESCRIPTION
• /!fit 1?7f` 50+4-16A 1- 01) _...
r
NC Well Contractor Certification'Number .'1.5:OUIECASING`(fo%`ioli'a eedtweIIs)`"OBL1 ERi( ' el f`-: -.
Yadkin Well Company, Inc. • FROM TO DIAMETER THICKNESS MATERIAL 0
Company Name ?:
ft ft. in. ,
`• '.z16IL R•GASICODR:XQ)3ING aitheniaTdo"s lotirif
2.Well Contraction Permit#: Z 0):2+ ' I Ct ( FROM TO . DIAMETER THICKNESS MATE�RIA"L
List all applicable;wel1 construction permits(i.e.UIC,County,State,Variance,etc.) -f-1, ft. ,6 a ft 9��e4 m• sip -2` P (
CP
�:: - ! ft. J ft v M. di
3.Well Use(check well use):
Supply t"�.7.74 tit ;:_:;.: :721?.-'; : i ::.,., s::.>
- -- .... ....-M 1'. w :,.,,,-`•_�<::' ' Ci
Water pp Y Well: FROM TO DIAMETER R.R SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunioipal/Public ft ft in. '
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft - in. 0
•
Dlndustrial/Commercial °Residential Water Supply(shared) 4-i$ CYOUT:',"'y xw . `::'�., "M i •,:s`a;. �. =C-..-».1."''::x`.''
LllnigationFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑wells>100,000 GPD
Non-Water Supply Well: 6 ft. 90 ft c ?s Irau 1-'� )3a445
•• ❑Monitoring - DRecovery • ft. ft
;Injection'Well: ft. ft
❑Ag ifer-.Recharge a •❑GroundwaterRemediation
azg IC19::SAND/GR9; .I 'C (d'iniff"t T4s....•Y,. _ ..,
_:'i.:R `:F,, r2S"__.._-",..,!i: L:.••
DAgiiiferStorage and Recovery • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwateiDrainege ft ft
°Experimental Technology - ❑Subsidence Control it ft. '
❑Geothermal(Closed Loop) ❑Tracer %2013)111EZIN r'I:OG.(attach additiiinaI'shee`taif'ueceisiiry'):';=;'isi::.1;":=i:'=::-= ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sollhoek type grain size etc.)
Date Well Started/Q.A-V (9 s. c ft ➢t Y ,� /►
4.Date Well(s)Completedi tF.3721 wellID#/ 32V? ft 'Xo ft S I> d'oPi c
5a.Well Location: Phone#:1 -3��Q -C.i' Zt1O ft 50�ftlud 11 M- 5r(7 gtzine k.
�± a:i b • ft ft,
Dana A
Facility/Owner Name -_- F Facility lD#(if applicable) ft _ _. ._r - ,,,. ,_
$Sl77 t 4 J:- oh a ec eer/'/le- ft. ft Nov 1 S 2021
Physical Address,City,and'Zip" - it. ft
',=.,-+- ' i:`•21'dliarA�5lLS,;.ic= ..,...,:i�. +:;t-. .;_-...�`i?.a:..;. .,...."::c".'_.�is.•;a? :
Cta , Parcel ldrnfifcationNo.(PIN) , '
_ Sb:Latitude and longitude in deg▪rees/minutes/seconds or decimal degrees: i.
(if well geld,one latdong is suf6cieut). 22.Certification:
l•' IC, 2YZO N �•Qa Si26/O w e- fai ^
029
•
� :gnature of CertiSed Well Contractor: Date
('< 6.Is(are)the well(s): 151 rmanent or OTemporary
`..- By signing this form,"hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ex( 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy A
gilds 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 baying 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: (ft.) Submit this GW-1 within 30 days of well completion per the following: CY
For multiple Wells list all depths if different(example-3Q200'and 2@100)
/n�� 24a. For All Wells: Original form to Division of Water Resources (DWR), .....1,.....1,10.Static water level below top of casing: �.l` (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 .,..,
If water level is above casing,use"+" nn,, ro
(in•)Slt Off: %fl,0/l� 24b.For InjectionWells:Copy;to,DWR,Underground Injection Control(IUC)
11.Borehole diameter: ty' Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:44r- P-4406'•5,. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
':•ti (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
t Permit Program,1611 MSC,Raleigh,NC 27699-1611 4
13a.Yield(gem) Method of test: " � t'-f y,2
``' 70% hth Date Site Visited: 7 i T 6—9`
' 13b.Disinfection type: Amount: d t Oz Site Visited By: b
I ,
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
1