GW1--05185_Well Construction - GW1_20230814

' ✓Jb'ELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:.Jec t e
c1 ('h1CIv)} Q 4i•:WATF.R`ZONES .-- _ '.
FROM TO DESCRIPTION
' Well Contractor Name ft. ft
0LiSD A ft. ft
NC Well Contractor Certification Number I5:OUTERCASING(fo"r"m"uitP ii'sedweE)ORLIIdER(if,'a-licibTe). ' ' - -
.Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name /� h,+ 'i16:INNERCASING.OR..TUBING(ge'titlierinalclosed=loop� ..' :_-- . - -:-. ,'
2.Well Construction Permit#: / ?l,@ FROM TO DIAMETER THIS S MATERIAL
L I ft. p in. P
List all applicable (Le.able well construction permits e.UIC,County,State,Variance,etc.) `a �O�ft. 6�®® I 7�Q Re - I'
ft. ft. in. VI
3.Well Use(check well use): • VI
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL�J
❑Agricultural ❑MuaicipallPublic ft it e
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft in. ,q
❑Industrial/Commercial X.esidential Water Supply(shared) :,18:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. S" ft. v(C RF pV Vc e+) ���y5 (73
❑Monitoring DRecovery 5 ft. /®(e, it anck(&cv(J PVttara /0 ES r%
Injection Well: ft. ft +�'
❑Aquifer Recharge .❑Groundwater Remediation
j.:19i SANSIGRAVEI;PACK(if:npplicable)'. - '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -A
[Aquifer Test ❑Stormwater Drainage ft ft. ��- ......-
❑Experimental Technology El Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer `20:DRILTSNGI.OG(attachadditibnaisheetsif'iiecns'aiy)': .... --.
FROM TO DESCRIPTION(color,hardness,saillrack type,gain size,etc.)
ElGeothermal(Heating/Cooling It tam) 0 Other(explain under#21 Remarks) Q ft. ft. S l
Date Well Started 1i 9' 3
4.Date Well(s)Completed: 1 31 133 Well ID# ,Tl t-r— ,3 3 R 3 ft. I(001-11't 6 ran t i.
Phone#:64
5a.Well Location:
i3-"3 84)-4XS �. ft. ft
ia+w ei ft. ft.
571-6i,`e- l'�,rs e�'t rat- 1/ -C 3&P . .� ::
ft. ft
FaciliTy erName Facility ID#(if applicable) ru\a C:f r 9 n
GjI3 Fat< 13 e.A-- c i PC-a a ft ft AUG
(( 1 J
Physical Address,City,and Zip ft ft C��23
��9 � i 21 RR'NMARKS... - - _.. .__.... ri-c'. ;,.i--.i,._.:, - . -_.
1494' . GI Gl`Y:`i'' .. ir.
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
3 4 1 G, 73., f2. N 3/ 3 9, /ff 8'd W (� -1(31 (.)3
• 6.Is(are)the well(s): ltPermanent or ❑Temporary Signa ofCe ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)construc"ed in accordance with
7.Is this a repair to an existing well: ❑Yes or *to ISA NCAC 02C.0100 or 15A 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 421 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: L 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14 014 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: f S® (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"/! ems/
11.Borehole diameter: 67 (in.)Bit Off: S,9 77 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: V&-/461,1^v 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(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
13a.Yield(gpm) - I Method of test: Aa
(r Permit Program,1611 MSC,Raleigh,NC 27699-1611
o /,� Date Site Visited: 14 `-� a. - 3 �,s
L.
13b.Disinfection type: 70% hth Amount: G"- OZ Site Visited By: 1/le n
..A
Form GW-1 North Carolina Department of Epyirommental Quality-Division of Water Resources ._ Revised 6-6-2018 -Ss
Price: .` -- 1) 7