GW1--06202_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.W94ConiractorInforma l
L (-00Y e, FROM TO DFSCRIPTiON
�J er✓'�l ti .. r4.WATER ZONES•::_'.:.'.:::
Wellb e Name_ ri 206 ft.l/io ft 6,)/1.0—..
„P.- g ft a ., ft ./S 474
NC Well Contractor CettificationNumber ..IS."OUTER CASING(for multi-cased'*rvel s)GRLINER(if;ap hUSIA": __}
.-...•:'-•"
•
Yadkin Well Company, inc. FROM TO DIAMETER THICKNESS MATERIAL
+i ft 1 CH it 4:;5 in. ;i6'iSr Arti--key
Company Name 16 JNNER CASINO O1t.TDBING(geot}iei maldosed=loop): _----— -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /20 336 ft it p
List all applicable well construction permits(i.e.USC,County,State,Variance,etc.)
ft ft In. L•
3.Well Use(check well use): _� --- C'
OM TO - -
Water Supply Welk FROM TO DIAMETER SLOT SIZE - THICKNESS MATERIAL it
F❑Agricultural DM cipa]iPublic ft. ft in i
❑Geothermal(Heating/Cooling Supply) i esideatial Water Supply(single) ft ft ill. 3
❑Industrial/Commercial ❑Residential Water Supply(shared) •.i8 G10UF; _.
❑Wells>100,000 GPD FROM TO MATERIAL �T METHOD&AMOUNT -
❑o b f. 3 ft twitirs l 4of...,r!..,_�
Non-Water Supply Well: Q to _
OMonitoring ❑Recovery 3 ft a ft L'Ytk1t,k y to,4 .ta
Injection Well: ftft G _ _
[Aquifer.Recharge ❑Groundwater Remediatien
.19.SANA/GRAVET P.ACK-(if iliOlicable)-.__---- ----` - ': -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑StormwaterDrainage f- ft
[Aquifer Test ,
❑Experimental Technology ❑Subsidence Control ft. ft ___.:_. __ ��
❑Geothermal(Closed Loop) DTracer ".. O DRILIBGLOG(attaci iadilionil-sbeetisifnece3isi)) -FROM TO DESCRIPTION(color,hardness,sairaek tYPe,grain she,ems)
DGeothemlal(Iieatin_C. .••gR-,y ❑Other(explain under#21Remarks) ft. P C •ft Soy ! ���,/,� k7101.--c..• Date WeII Started< �i�l._..-1 qq ',� b / pt .E .�
4.Date Wells)Completed: f Vr 93 Well m# v7/' 46 ft. 17 S ftLray s g r4. ye it f 5 C>wx
Phone#: s 13C.-?©?_o%7 r'' ft 14 P ft ,,,,..`. ..e-yi' 4
5a Well Location: '4 33C—Pts 32. �� i R. go ft 6' ... l�y4,3o �! •�'6
e ✓
Facility ID#(if applicable) ft' A 7 '�rt�'
Facility/OwnerNeme ``
// i.L 14d�val IQ- ,p e ft. id \L.L.'i,®ill `t U
� ��T�L �11I y,�1�Physics]Address,City,and Zip arr) ft ft .SE'_ tD 5 ri .
L^ ._" -
DGS v i �ui4''�•? tti".^(s3,�%a rta I F,-b
County Parcel Identification No.(PIN) IFlt `Ar^.119?
V.a4".�,
r:.t)1,e
Sb.Latitude and longitude in degreeslminntes/seconds or decimal degrees: .
(if well field,one 1st/long is sufficient) 22.Certific an:
3S 2( k2.7 N ka, , -1 2 ( 1 W , , /,---•,. agl �.-.
Sign e o Certified Well Contme or Date
6.IS(are)the well(s)r Irmanent or ❑Temporary
si 'g this form,I hereby certify that the wells)was(were)consoucted in accordance with
7.Is this a repair to an existing well: ❑Yes or Ill o 15 CAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
1•f this is a repair,fill out lmown well wnsd uclioo information and explain the nature of the
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 having the same You,may use the back of this page to provide additional well constniction info
construction,only 1 GW 1's 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 land surface: 9,6 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(g200'and 2(g100)
/� 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: �` (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6,0?7 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
11.Borehole diameter: (in.)Bit Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f A.-Y- gelf 24e.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)
t�,(
s Method of test: Apip Permit Program,1611 MSC,Raleigh,NC 27699-161I
6-g" ^ aJ kov 4 C��
Date Site Visited: 4 -2 O-23
13b.Disinfection type: ---` 0
70% hth Amount: )1 Oz Site Visited By: ,)3'L- reg""'� a,,k"04.` 4
20186 6- -
Form GW-1 • 'mental Quality-Division of Water Resources Revised V
Price: • ` , uj
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