GW1--05153_Well Construction - GW1_20230814

r,Ai LL CONSTRUCTION RECORD (GW-11 For Internal Use Only: S
1.Well Contractor Information: Q)
C/tp t �S1C/b✓1ti' - ki/a (-14.WATEZONES .- . •' C.)
PROM TO DESCRIPTION / L
Well Contracto Name 5o 1,6 g - AJ ft. yde ft TGQ1A S s"s/�� true,ea-ae�>d
ft R.
NC Well Contractor Certification Number IS.OUTER CASING(Ur Mold-Used wells)OR LIMA(if i UcaAle)
Yadkin Well Company, Inc. PROM , TO ' DIAMETER THICKNESS MATERIAL
Name
'1 ft. 6 Y ft _4,1 ��v/1,di ,v z "CompanyCoay ,' 16.INNER CASING OR TUBING(pebtheroaal lased-loop) -
2.Well Construction Permit S: PR4.01.2.'21 Of V'34 FROM TO ,DIAMETER THICKNESS MATERIAL
lltt aQ applicable veil construction permit(Le.UJC,amply,State,Variance,eta) ft. ft In.
3.Well Use(check well use): ft. n In.
..5
water Supply Well: FROM TO DIAMETER SLOT SIZE TarcJa+rss MATY7tIA1.
5.,, eulnual OMtmicipaYPublic ft. ft. la. 31
°Geothermal(Heating/Cooling Supply) residential Water Supply(single) R ft. in. _1
Olndustrial/Commercial °Rr idential Water Supply(shared) II.GROUT
Obagation Dwells>100,000 GPD FROM TO MATERIAL Eriale��fr?. ODStAMOUNT
Non-Water Supply Well: .,-.. a ft. r ( ft ft. A f,fav it et ii o isok" pia` e/
("°Monitoring .�r t i%!tj,RZc y y ft. /if4' ,,���fff...4J C
Injection Well: t "'
ft. ft
❑Aquifer Recharge AU G i 4 2 Ar oundwater Remedinftm a
u 19.SANINGRAVP.I:PACK(lf appllnble
°Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLAfL'�rrMETHOD '
..,..-'r':.;'r1 nwat ft. ft
°Aquifer Test lrc�::F ter.s .r,•4OStntmwnterDrainage
°Experimental Technology t'•''z"' - °Subsidence Control ft. ft
OGeotherm_l(Closed Loop) OTraeer •'IO.DRILiAGI:OG(ranch iddldnnal abuts if necnsary)
°Geothermal(Heating( oglin: • . .. °Other(explain under#21 Remarks) PROM TO DESCRIPTION(enter,hardness,sevrcck type,xratn nee,etc)
Date Well Started 1' ( p /► �� f� 0 " Ye) 1t t�Yrest i�? /r/,(Dt AN
4.Date Well(s)Completed:7D.1t1(7/0 well m# 4,4 I go ft. co ft- a7 e le s I%. (L ir M'Or 94/j/ .✓c y A
5a.WelLocation: Pho #:3.G- $10/- 73�S /�v ft 6v n- nO/<kf a�L�` 1t7�4�r a �J, (,
MILLae/ Evay I l {Iu.O(yC vf.h Feti,V f0 ft. til1.1t Kat fa. t i y l<-I C i , /a M . 5
Facility/Owner Name Facility IDS(if applicable) 'r'��2 it ill f 1 47 c f . 1,1 r Y i1�-� �'� n
4 7 Z r N AA R& S4efIa I c R. ft +` Y �1 -
Y R. ft
Physical Address,City.and Zip
A4R3d/4,a _ ! b.,(
/Sy yv� ParcelIdentificationNo.(PIN) Ii7CLp..�OrJ rS4-
ci
CW�Y nn �' Q
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d �flt� ^�a1 !f t�0v I (( r"o .
(dwell field,one lat/locg is sufficient) 2.Certiflea on: JgJ t 4- a,
36. 36ti.1" N S'o. $23/3 w 11). eC 2D 4y7045a3`
6.Is(are)the well(s): bli4rmanent or °Temporary s' ofCenificd Well Coctnctor Da -
t!
l signing this form,I hereby certify that the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: °Yes or t!No ISA NC4C 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthb is a repair,fill ow brawn well construction information and explain the name of the of this record liar been provided to the well owner.
repair under#21 ranarb seettan or on the bock 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 OW/1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface �J Qpa (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdi fe ent(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: 41' (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use"4."
G. �Q� 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Co (in.)Bit Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Pt .I' i 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,able,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: etuil‘ri
24d.For Water Wells roducin over 100 000 GPD. Copy to DWR,CCPCUAf Permit Program,l 11 C, eig ,N 2'1 9-1 11 .i13a.Yield(gpm) Method of test:!1 �,.1 a
a Date Site Visited:51'20 -Li G'''J"t / �.l -�
13b.Disinfection type: 70/o hth Amount: ' Oz Site Visited By: 073 Na s 4 s k‘ _
Car ina De neat of E •ronmenta`Quality- ivisioe of Water Resources Revised 6-6461 w `
J'atlSed W