GW1--06855_Well Construction - GW1_20231030

I
p`ji t �U CONSTRUCTION RECORD (GW-1') For Internal Use Only:
1.Well Contractor Information: ,7 ,
G_� �'L-1 \)-eo/'O y S/� a uI4?,WAT ZONES :Fri =fir: ..i- '.i_;i '
Well Contractor Name S / FROM TO DESCRIPTION
a�°3 _ j . jss ft 2 far
ft. ft
NC Well Contractor Certification Number ISi:O UTEE:Ce1SING.(foi mnllitccased:wells)•:ORLTNFJR'(Sf:a'p`licalile)s
Yadkin Well Company, Inc. FROM TO DIAMETER Vita:NESS MATERIAL ;-3
�vg� / 1 ft u [,I} fG ✓y in.
Pg..�] PuC-
Company Name�a f C��� ��a® c "�. "7 r.�t� 11 [ gGi(a N - ---_.....:,-_.�.
® � 'i16IIVNER•CASING:OR'TQBING(�e"otTiermalclwed=loop)`_-=>!_---_. _::;�:__r.
2.Well Construction Permit#: 0 FROM TO DIAMETER THICKNESS _MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc) ft. it. . . in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: . 17 S 7.+_ .:`_`-. �_:`.- .__ -----2..:2:.:_..
FROM TO DIAMETERy SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Catesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residenfial Water Supply(shared) _18?GRODTC �`:_:�=�_� --_- --- ------
❑Icigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
)
Non-Water Supply Well: �* L, 4t, g ,,,
tt 9a, ft lk its if y d PAC.e-
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge .0 Groundwater Remediation 1_19:SAND/GRAVEIi_PACK'Cf:T'hc"alile L-'-- ---_ ________._
- -- _.. -` ._-'
DAquifer Storage and Recovery ❑Salinity Baaier FROM TO MATERIAL EMPLACEMENT METHOD - '
❑Aquifer Test ❑StormwaterDrainage ft' ft'
❑Experimental Technology ❑Subsidence Control ft ft
DGeothermal(Closed Loop) ❑Tracer ;20iDRII;tINGI:OG•(iittic-haaditiiiiii sheetiifriece�ary)=_=___._.:=
❑Geothermal(Heating/Cooling Return) 0 Other(explain und/er#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUroek type,grain size
etc.)
Date Well Started a c d� _•
A ". et 0 s. f� ft 3 O tt( 4-((e 4Z ( pa •
4.Date Well(s)Complete.: 6. lD ell # . 5 ft. q e ft /f i C/�,•I Ay�&rs
5a Well Location: Phone#.3 7(- t 3.idlo fteks) ft
"a bet QN C ;- 10d}, ft- „9, ft- Epr•!� A„ )7J e"'a'_"ef o . ,pf4
Facility/Owner Name Facility ID#(if applicable) 9 8 ft 1�9a ft 6L/� / Gar-e y LT p
t'3 /"t 4 c?TGt F-aac& f. ft.
U le N
Physical Address,Ci y{,and Zip /G ft. ft. .,r^ h
v 7 J l T\YI r-2LIRRMA'RKR:::-' [�...�`� __7i--_ _--Y ...--�i J- _. �_
County Parcel Identification No.(PIN) OCT J J 2 �,j t
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r^ :.
(if well field,one lat/long is sufficient) 22.Certifica,on: 10i"' JL'��° '•f = Ci
3C ' 3 2C.3-7 N ESQ, 70 S-C, W : ���� ����
6.Is(are)the well(s): �rmanent or ❑Temporary its. of Certified Well Contractor Date
/: 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: ❑Yes or niVa 1SANCAC 02C.0100 or ISANCAC 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 1121 remarks section or on the back of this form.
23.Site diagram or additional well details: . C.3)
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 03
construction,only 1 7-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. l v
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(fdfferent(example-3@200'and 2@100) _
24a. For All Wells: Original form to Division of Water Resources (DWR), Q
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: Ca (in.)Bit Off:'Q; 7.5 9. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(RTC) a
a •( Y Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A,tr 1
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (.0
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 Permit Pro
13a.Yield(gpm) Method of test: u✓ gram,1611 MSC,Raleigh,NC 27699-16
V Date Site Visited: 7- 5 -2 3 i
13b.Disinfection type: 70 o�o hth Amount:- ° fd OZ Site Visited By:_ ,corp I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018