GW1--06849_Well Construction - GW1_20231030

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:LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
Cirt)°"is1 / G�tsty�/ 4.) . i..1&:;WAT..eat'ZONEs Vi ..,;;:a"s#;•! v5:: -:--.7i.'_;•l:;9: ., ,':"-Iii..17,1...... .._...;tis;',
Well Contractor Name FROM TO DESCRIPTION
3D3g - 14 go ft. 's,'ft 100 6Pry
ft. ft.
NC Well Contractor Certification Number .i15'OU'PERCASING'(fdi'mniti=cased ivelli)'OR7:IlVER"(ifap'lielble)t `.;"?'.'11Px
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MA
Company Name * 1 ft. `3g ft. 4,1a6,in. °pg_9( �� �
�j :�16 INNER CASING.OR TUBIN G:(geotber mil:rloTeed:Ic7rip) '. •'',.�i.:;.: .. ._
2.Well Construction Permit#: ®( 8 I ?C.--2_0 2 3 FROM TO DIAMETER THICKNESS MATERIAL ,.r
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .7xaSCEtM.'� :1'v=.7.i: - 3__7 .7.:: �- _•..... :.:..i.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft ft. in,
0 Geothermal(Pleating/Cooling Supply) idential Water Supply(single) ft ft. in
❑IndustriaUCommercial ❑Residential Water Supply• (shared) :.,:18:.GROUTI:w , ; :z '.,te__,:77. , : -� `—
❑Irrigation ❑Wells>100,000 GPD FROM TO MA EMPLA OD St LINT
Non-Water Supply Well: 0 ft, 03 ft Irj ��t� / y i, Vt
❑Monitoring h... ±Y:t ,s_.t , r' ecoery f. ft �g '
Injection Well: '".. "'''''' rz
ft. ft
❑Aquifer Recharge oundwater Remediation _ _ _, �_-,
0 C T 3 0 20 i 19:AND-MBAVEIIPAGK'(if applir4iile) .`•r = . _
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD J ,
DAquifer Test ttl ^,.:1 %'r•'-^r{:.tlatdrmwaterDrainage ft ft
❑Experimental Technology e",'-':t:;`vr,7 0 Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer L30 DRTTLINGZOG:(afkarlilidditionalrsheetaifnecasary);,-_. ;—"`V= `".W. r
❑Geothermal(Heating/Cooling Re ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/roelc type groin size,etc.)
Date Well Started 2" s'e:' ® ft .2 ft. fir
4.Date Well(s)Completed: ►'.> b /93 Well m#t R 1 9, ft. f® ft. L,ea-y;d--j s ai! e/c
5a.Well Location: Phone#: 36-g'� =7?( ? I12' ft � ft �4�d1/�,,cao.....gDe% a ,e
411' 4-c ii Cir(41,164- 0'5-- ft' 21 ft. Gve..n,p j4 _ rive/ /943 ci
-
Facility/Owner Name Facility 1D#(if applicable) '3' q ft J O D• ft 60.0.4k 6� G 14- Aids
/?o/ �r.�a 6✓
et ir'e'e`rl- i I P ®4t101/G- r o a f`- Waft ft (�•vs4o e 1 r✓ 16vey I !A/I]tb�!/ 'La '
Phy'coal Address,City,and Zip - • - ft. ft
County Parcel Identification No.(PIN) '
, o
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degree's: , •
(if well field,o®nelat/lloongissssufficient) �,p� C P ` 22.Certifica:,n:
3 .- �r C .G 1 d , N �?4...P o S,.s�5- 3 W .i r. 0o`��C �®'/ 13
l . -
6.Is(are)the well(s): 11P(rmanent or ❑Temporary of Certified Well Contractor ' Date <
s-siermtg this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nit: I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
,.q 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 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. a
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r (ft)
p depths if different Submit this GW-1 within 30 days;of well completion per the following:
For multiple wells list all (example-30a 200'and 2Q100') 93
10.Static water level below top of casing: /S (ft) W
24a. For All Wells: Original foim to Division of Water Resources (DWR),
If water level is above caring,use"+" Information Processing Unit,L617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (lift Off: 5P/Q 39 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)
�' Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A eta f9 � y 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing!over 100,000 GPD:Copy to DWR,CCPCUA
/®� 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611 1 °.
13a.Yield(gpm) Method of test: i it I ' ry rivvi
o Date Site Visited: e-/V-,2 3 I
70/o huh t "
13b.Disinfection type: Amount: OZ Site Visited By: I
Form GW-1 t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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