GW1--06968_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only: i 6...:
1.Well Contractor Information:
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WellContractorName 1 FROM TO DFSCRI/P,TION
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NC Well Contractor Certification Number :15O W ""'
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Yadkin Well Company, Inc. FROM TO DIAMETER: THICKNESS 1 MATERIAL
ft ft f in.
Company Name s•C_�':'f
�� II i61:N:MGASING'ORUIIBIL�TG(lial rmal-rraga li op)"•;: t . ..
2.Well Construction Permit#: IA/ FROM TO • DIAMETER THICKNESS MATERIAL ,
' • List all applicable well construction permits i.e.UIa County,State,Variance,eta) + f ft 7.3 ft G in" 5DR.o I. AvC
3.Well Use(check well use):
ft. ft in
Water Supply Well PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
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❑Agricultural ❑MunicipalfPublic ft. ft in.
❑Geothetnial(Heating/Cooling Supply) Residential Water Supply(single) g• ft in.
❑Industrial/Commercial DResidential Water Supply(shared) s
PP Y 18:,CHOU 1�`^ aK,;,• 4 s•'.. .e l , •
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' ❑Tniga-don .. - -- -- -- ❑Wells>100,000 GPD FROM TO MATERIAL MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply WeIly ;T •, ;s 1 , t. "Z3
PP Y � -- .- � 0 �• er.J � �'ib�e P�vr� Pou�e� /0 �4sS
❑Monitoring t ,pAt}covery ft ft
Injection Well: NUV 1 ' U[LL ft. ft • -
' ❑A.quiferRecharge ❑GroundwaterRemediation hw,
ji'19I:S6.NDIt411:0.0D_PAi (i 'licaliIe ',-TI::17.rsi.'.=-•,::.�.__�' ='t. •
❑Aquifer Storage andlRecoveryr�'` --'DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
DAquifer Test. ❑Stormwater Drainage ft. ft
❑Experimental Technology El Subsidence Control ft ft. ,
❑Geothermal(Closed Loop) OTracer f120 3) IGT.OG(atf 'naditi"on lsheef33fne e.sa y)''?a is:V :E»`''"<' -,"..3 1s.
FROM❑Geothermal(Heating/Cooling Return) CI Other(explain under#21 Remarks) I TO I DESCRIPTION(rotor,saraaess,saWrock type grain site eta)
Date Well Started J01141344 • 6 ft '1,0 -ft ' Jam.-./ -
4.Date Well(s)Completed: (OJI (24 WelID#ilk.'451i t . 100 , '03S- it ,GrQ tr •
5a.Well Location:, Phone#:33(,® ti7Z' sD1 A.Vt. Zysft, -‘131- e2ocI
8 2gS fr••;i3p3,ft' carii4r
Facility/Owner 4 ine Facility ID#(if applicable) . ft ft
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A 6aid fr Z®(ta 1 j_. akelth Allis ft ft • C
• .. '"PhysicalAddress,City,and Zip NC f�6/_ , -f ft T'
•. W 'i Y lU ;i21'allyre 11C.n,,,g.. ;.':T,, :::1;:_^.,::':a1:.. •,':: ::.^..: .:i iT:. :i".:�._::1:. . .,!.c..+':: ...
County., /, Parcel ldentification No.(PIN) 5 GPI ` 'b_•'10 re
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: is- GPf)i AC ter' rCAc.lc`n1C� Do
• (if well field,one latllong is sufficient) 22.Certification:' ••! •
• 36 ° b ' id A, .N 697' 0f' 2z a w t•
o[ig1y
6.Is(are)the well(s): Permanent'• Or ❑Temporary
Signs of C rtified Well Contractor : Date '
- By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ) co(I 1SANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
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 remark 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 pis needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
1
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 303 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths yid jerent(example-3@200'and 2Q100)
„�Sd ( 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
® ® 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �%' (in.)Bit Off: •��O Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: et s! P'r3 4 A a«s 24c.For Water Simply and Open-Loop Geothermal Return Wells:Copy to the R
(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 4.
9 Permit Program,1611 MSC,Raleigh,NC 27699-1611
132.Yield(gpm) 15 Method of test: if 4 i,/
70% hth Date Site Visited: 7" 2 .t 2 V-
, 13b.Disinfection type: Amount: ' OZ Site Visited By: " AI
z-.,...•, - *r ^t,_c..-•-ram- apartment ofEnviromnental Quality-Division of Water Resources I Revised 6-6-2018 '