GW1--06252_Well Construction - GW1_20230925

'\X se'',"[.CONSTRUCTION RECORD (GW-1' For Internal Use Only:
1 Well Contractor Information:
CRLj 0(1Ge( / IA, 'I4=:WATE$7ANE5 rt '..:Vat i ''r' :::ti° ;Z.:ai,,..:.,__ .`•'; ..r;_i
Well Contractor
�NN a FROM TO DESCRIPTION
3b3U /4- O ft. (00ft. / G'PV
3Sit. o4p ft Q. ale„,,`
NC Well Contractor Certification Number 1
:IS::OU eLS TER:CENG'(fdimtilti=ce'sedwells):ORI.INER(ifap lielble) __: ia,iZ
Yadkin Well Company, Inc. FROM TO DIAMETER [THICKNESS MATERIAL , ra,
Company Name T I ft. "-7 el fr, /,)as ia• J!/(i'ds t f v L r
�p YY r p, 16 `NNER'CASINGI.OR'.TIIB(BING:Writliermalelosed4.340::ax: "Y==, `--r•- a3:: (Z
2.Well Construction Permit it: O( ) S gs , 2.®�3 FROM TO DIAMETER _THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft it hi. t\b.
.�
Water Supply Well: ZilT•''SCRktk u �: "-� 2'__',-.�-- �__,..—- _:;:ii�V,
FROM TO DIAMETER SLOT SI7R THICKNESS MATERIAL
❑Agricultural ❑M cipal1Public ft ft. in. s
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) "187I tOUT; _.' `':,` -`-'" ---- _ =� "" `-"-2
❑Irrigation ❑Wells>100,000 GPD FROM TO �BMAT1ERIAL( Ito METHOD&AMOUNT CA
Non-Water Supply Well f i�...1-%E.�i 1 9�r"'n v ft. 9_3 ft. £€rt fDil t�•le L i' o t I PlAc-t_ 0
❑Monitoring I 't L.1.1'L.co e&ivply ft O ft. 1 5 60
/ 64143
'4 `(�
Injection Well: c C � (3g ft 6 LUJ q
DAquifer Recharge J C P dwater Remediation .. _`� _ __ •_J
�1'���r in.14AANDlGRAVF_EPACK•(ifa folic'alile) ..r°f
❑Aquifer Storage and ReuCoie�y ,i,. is -„la§4:t y,$drier FROM TO MATERIAL EMPLACEMENT METHOD ,•
❑Aquifer Test DV i:M IStormwaterDrainage ft. ft
❑Experimental Technology 0 Subsidence Control ft ft
❑Geothermal(Closed Loop) OTracer r20 DRICIINGI:OG:(ittuh'sdditio`iwlrsheetsifaecnsaiy- ,:.
OGeothermal(Pleating/Coo.. Return) •❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,'hardness,soillrock type,grain size, ~
Date Well Started' co' r Q ft 5 ft- Snr I¢' OD$e- _.®,--e---
4.Date Well(s)Completed: 3Well B# ®�' ( Li 5 f. . 45 ft (,,e3 -f r, "{t,� t,oc kC e t{'1(�.�Ort
• 5a:WellLocation: Phone#: 34-size-iir}Lg 4 S ft. (((2e:i ft /t .� 1/G . 1�/A.
L Ff.rC t /c iL eJ // it it)f.ft. (_yu:.n.r�L( (rerG��// c -(7� .
Facility/Owsl Name FacilitylD#(if applicable) t6() ft- inn ft t, Apev•5 y �'•/ �R` i, J
• F,v 1. aA. /mead" I b r�
Physic�all Address,City,and Zip ft. • it - �'
Yell l&k iv r r -__ - .--: _ - _ — ____.._=
•
County Parcel Identification No.(PIN)
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
n
(if wellfield,one lat/long is sufficient) 22.Cer;r cation: '
f- Cam., .. la 66U ,. N RDr 5-93-08 W �/ �
6.Is(are)the well(s): I ermanent or ❑Temporary Signature o �►a'4sed Well Contractor ate
�� By sign',g t. form,Thereby cemfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ltIi' 15A N ' 02C.0100 or RSA 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#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 construction info
construction,only I GW-1%s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below landsurface: 3, (ft.) Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths if different(example-3Q200'cud 2Q100)
L y -":'24d' Fiir`.All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /V (ft).`•.:jnforraation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" t°11.Borehole diameter: 6 (m.)Bit Off: + ; ' •s '
°y ,,24b:For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
ri 9 70 pro gram,1636MSC,Raleigh,NC 27699-1636
12.Well construction method: IV- t y 24c.For Water Supply and OpentLoop 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.Fir Water Wells pro ducing;over 100,000 GPD: Copy to DWR,CCPCUA 1
Permit Program,1611 MSC,Raleigh,NC 27699-161I 2
13a.Yield(gpm) Method of test: t Date Site Visited: -I .2 '2-3 c3.41v ¢ re.vi- '�2
13b.Disinfection type: 70/e hth Amount: OZ Site Visited By: b i I •• &lax e o
Form GW-1 North Carolina De artment of .^vironmental /�� ��
o '' Quality-Division of Water Resr. . ources Revised 6 6-2018
Price: P4, -