GW1--05340_Well Construction - GW1_20230818

. "'C CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
M l �6 �e - . . . . .
/ - • !,14:WATEI2ZONE5:"i.:.;:l-;":` : :
WellContractor N�e FROM TO DESCRIPTION
�3�`'t7— A 1 I L ft. 1(S ft GPM 3
19Qft 139ft 155
NC Well Contractor Ceitificotioii Number .15.:OUTER'CASING'(focivtila=case wells).ORL1NER"(ifitilieable),_ _'__ -...- -
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
!�V `16 INNER'.CASING.ORIIB.TING.(geother'm alclosed-idop). - - .._ .
2.Well Construction Permit#: Cl T(, FROM TO DIAMETER THICKNESS MATERIALra
List all applicable well construction permits(i.e.U1C,County,State,Variance,eta) '/�l ft C 10 ft. !/12 c in- 5O
Q 2/ p v c
3.Well Use(check well use): ft. 1 ft. ® in. r
Water Supply Well: aa.9 CREEIQI :.. __. -- _.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 3
❑Agricultural ❑MM/unicipal/Public ft ft in.
OGeothermal(Heating/Cooling Supply) M esidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) - . ._. .. _-. -:. ._ - ._ .
c18 GROUT:: . -_ ._. .-C
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AM UNT co
Nan-Water Supply Well: 0 ft. ft tion�v,,it )•
(
' 0,C.��
OMonitoring ❑Recovery ft. ft. /3 "i~(A S P
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation C J
I:19.SAND/GRA-VELPACIC(ifappli"cable): ._---- - -- - -:_...1:-- ' T .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' t'1
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer I':10:DRIL.L•INGZOG'attach`ad'ditional'sfieets`ifnaceiii
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saillrock type grain size,etc.)_
Date Well Started /i_]0-2_ _ 0 ft. 5 ft Jo,/
4.Date Well(s)Completed:'..(I'-)3 Well DMA-14 -6 9.S s-a ft. 4s- ft Off s`v F� 1_ 0
t�soco. /rti1�
Phone#:52tr-.UGC-- Y72)" Tr ft. 163 ft. .St F+- `�Sa Well Location:`. /1 ,- p l r on, C. -CD
11V (f )11,110, CA t�lm.��/�C�( c'efi )°9 ft. f'L ft. �r�i'f� Cjfa� f row.I ��nr G `t'1
Facility/OwnerName Facility ID#(if applicable) , II- ft' 31 ft n, r V
® ` y tD0,1i -i
S732 7' -ip/t (a to F 6 Y 1 the.,L . ft. ft. gyp•
Physical Address,City,and Zip it ft. I-'c i ' 1� �j�,
k) j w✓- P� t.2L'RE1YARUSg;:'.:'..t ::.:._u_' t-:.; v"_�: •,_!. .-. .. .-
County Parcel Identification No.(PIN) AUG 1 8 2023
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ll°ti‘.,+,,,. r':;, -"G.e:�+z.i iti,;
(if well field,one Iat/long is sufficient) S 22.Certification: \ DWW'::OG
3Ce /(Qt'C N ?,Iii# ,2-- c'67gf w • //- 3
6.Is(are)the well(s): tg►kermanent or ❑Temporary Signature of Certified Well Contractor Date
By 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: DYes or ItNo ISA NCAC 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. t
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: . -.Z.
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. 93
drilled: CAI
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .3e0 (ft)
For multiple wells list all depths if different(example-3@200'and 2Qa 100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water Ievel below top of ca e
sing: (1 ® t) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(f
If Ovate level is above casing,use"+"`` Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 Cm.)Bit Off: S. 5/ 0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: (f3 I-Ar
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) g 0 Method of test: 17 I Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited:9-2 st-2? e;t mat.1 b‘c 6-/a ph.c -c:,
. 13b.Disinfection type: Amount: 7 OZ Site Visited By: .0 In
Form GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: