GW1--06244_Well Construction - GW1_20230925

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LL CONSTRUCTION RECORD (GW-1) For Internal Use Only: >':
1.Well Contractor Information: • I 'i
C9C1)y Pa u.ICWA27Q.ZONES'e';........ C ;;'3-,T..:i?: se. .._.�:'Y;z;;=..,,z... ..- , . .
Well Contractor Name FROM TO DESCRIPTIO
{ i tisj'ft. (SO ft �1raa(1I 9° ATATE, 10 BP � cl + '
� � ft 1 ft
NC Well Contractor Certification Number f 15.OUTER:CASING(for•`:multi:cased"iveIfsy.ORIINER(it ap lica1i1e)_`_•__ - .
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. ' in.
Company Name
/�/i�// '.t161IPIIVER'CASINGOR TIDING(R-eotliei•m`alclosed=ISop)'<'j�'"_r"�:_ ::
2.Well Construction Permit#: D FROM TO DIAMETER THICKNESS 1 MATERIAL y)
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) 41 ft. 65 ft. 'J „ in Ii( Ail
�V AC,
3.Well Use(check well use): ft. it �c in. �"
Water Supply Well: 117•S.CREEN.='< . s �_ ;_. ___ .__ _ __='_: _
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
OGeothermal(Heating/Cooling Supply) X2esidential Water Supply(single)
ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ___-_. __.. _____
• (18i.GROIITt:,`�r�;: `_- `7'—• -
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. �.i ft l�6g mm;+y g,, , `3 5
• OMonitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑A erSto QeandRecove ❑Salmi Barrier i-19:SAND/GBAVELPACK(if:applicable)i_r1� :,.-.;_'2..__::_�_. _.-
ry t3 FROM TO , MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft •
❑Geothermal(Closed Loop) ❑Tracer 1.2l1FDRIXIMG1I:OG(art'achAdditional-sheeeta3fnecessary')w �=,_'�._ "-_ . 1
DGeothermal eatin Coolin Return) 0Other FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(Fi g1 g (explain under#21 Remarks)
Date Well Started g^8^-+3 0 ft. Llo ft. S.o /
4.Date Well(s)Completed: '9"5-?a Well]D# Aeqp-.`5 L ft. i ft 114 YY40at /t;h 51k� g�, `i
Sa Well Location: sli4IZ Phone##: . l5-+�-IN.-10®d ]Ai ft. Lick) ft sec,. Ily�h� day 6' l R'
aeta.., '- S,rhi' � 1,6 ft. 36'aft Par h Si-y # 8farli-e
• Facility/Owner Name Facility ID#(if applicable) ft. ft.
- :• L /I••5a{,4► �.ie6- 414 if-Zv AO. 7-I ft. ft
Rill/rag .
Physical Address,City,and Zip N C r��1 gta is ft ft
u21:RRT ARYCC;;.::'�z,:•�'' 72..:. :;' Z*.:,_._..7:::�7,1- .^ :'_3:--'-'
County Parcel Identification No.(PIN) 6 C.r I—: +ii fez
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S EP 6i 2 7 0
(if well field,one lat/long is sufficient) 22.Certification: " L 23
?G if, 6 7/9 Nei 1:16.b 31/ W . G ..,. rn.•1 n P,•_�., • � ��
GIf(:.:,tt 1_.
6.Is(are)the well(s):X'Permanent or OTemporary
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 o 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out blown well construction information d explain the nature of the of 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 GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well consruction 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: U 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: ) (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3@200'and 2Qa 100) y P g-
10.Static water Ievel below top of casing: 'CJ (ft) 24a. For All.Wells: Original form'to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit 1617 MSC;Raleigh,NC 27699-1617
11.Borehole diameter: e0 (in,)B it Off. 5 t5'7( 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Itto / 1-/fr 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 I
tr Permit Program,1611 MSC,Raleigh,NC 27699-1611 �----••
13a.Yield(gpm) Method of test: q/r' •
70% hth �� Date Site Visited: 'Y�5-.s . '.
'1
13b.Disinfection type: Amount: / OZ Site Visited By:
•
Form GW-I _North Carolina Department of Environmental Quality-Division of Water Resources , Revised 6-6-2018
Price:I-