GW1--06965_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .A
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1.Well Contractor Information: •
a
s e:�..yvl�s' H4 i( 14 WATE$ZONES=_- •1..• ,it X
FROM TO DESCRIPTION Z
Well C ntara/c9torNpame y t._121 ft 5 �7 . r c�y,,,, ?5?i& C)
6!br e - . .23 ft. 11/ ft ('� s p"w, cat JI Wl r
NC ell Contractor Certification Number
7 J ��
15i10UTER:CASING(Ditmulti=ell ed_iali:ORLINER'(ifa licalire).,__:::-,T -•_ r
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL 2
Company Name •
ft. / ft. 7 ' in. / /
®� ':1.69 NER'GASING:OR;TIIRING;(geotlie.imal`closed=to"'b iP;;;1 w___ . ':u:.:
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List List all applicable well corishziction permits(i.e UIC,Comity State,Variance,etc.) ft. ft. 64 m s 2sa 64.11. CTe,�f
3.Well Use,(check well use): • ft. / ft. t /, in. �J f J
Water Supply Well: t 7~SCREE17r� �M: ,:�:_:._"11 .:_-._ ----- --"-------
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ' OMunicipal/Public ft . ./-
❑Geothermal(Heating/Cooling Supply) ' ❑Residential Water Supply(single) it ft
it (s
❑Industrial/Commercial 2 C esidential Water Supply(shared) ;>18::GRosi`- _:._"_�'� 2,7-:.`-. :-- . __ _D
-AMOUNT
____
❑Irrigation ❑(Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTEMPLACEMENT
&
Non-Water Supply Well: Dft ft 0 drips . 1 i ,b4i5difrif�•Ntr,I7 •
❑jectoring ❑Recovery �c ft
Injectionn Well: ,,- ft ft7
DAquifer Recharge •❑Groundwater Remediation •1g_SAND/GRAVEL PACK if•apphcalile)' _- ---
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM . TO MATERIAL EMPLACEMENT TROD•
DAquifer Test ❑Stormwater Drainage /ft
❑Experimental Technology ‘❑Subsidence Control /ftt. ft. •
❑Geothermal(Closed Loop) OTracer r20: :7NGI;OG`iittacli'sddi 'niil'sLeetsifnedeis'ary)`,L_-.,:"._:_ �:
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness,sail/reek type grain size,etc.)
Date Well Started q v- 4- g-3 /11 Q ft. it 5®,;/
4.Date Well(s)Completed:10=6 li Well ID# A P-6� ft. P 0 ft co �o%1 D 41 6�,ot�S ,
5a.Well Location: G.Phone#:'37 6 �` ft• j 5 ft -` ikti Ioc•i,- Soft `
Facility/Owner Nam ''n Facility ID#(if applicable) 7 fL �©t ft 9 t(?&.O" I f,' y�p ;„ i/y fjct 2'
' , /4 X /`•r L�N't"y /+.r/o , - ` �®.ft ( 3 f. Jpri,.° 04ple�^/y had ..
Physical Address,City,and Zip So.;1'�B`a b� A. ,`°• 5�Zi. Val 1 6§IV' it Ci••• S®7�d- -..".1_
7Q D �! ' � .% 4a ti :21:RElraliKS:- _- _-_�t, w�_�:--- - -"---- -- -- '4
County Parcel IdentificattdnNo.-(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'n"` i*"-) i ')
" (if well held,one lat/ongissufficient) 22.Certification:
34. E2 g, ?6-3.7 N gi gSa 3737 w 7 20,23 '-
6.Isate the wells permanent or OTemporary SignatureofCertifiedWellCon clor. ,.n j-,-:, F:' f,.r r P ,.^ :,: !Le
By signing this form,I hereby certify that the ifielf(s)SVas riLere)constructed in accordance with '
7.Is this a repair to an existing well: ❑Yes or d To ISANCAC 02C.0100 or 15A NCAC 02C.020Q Well Construction Standards and that a copy '
' If this is a repair,fall out known well construction information explain the nature of the of this record has been provided to the well owner.
repair under#2l remarks section or on the back of this form. a\
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info (P !
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same a (add'See Over in Remarks Box).You mayalso attach additional pages ifnecessary.
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells ) p g
drilled: b • S 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: " .✓0, (ft.) ` •
•
For multiple wells Tilt all depths if different(example:.3®200'and 2QI00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (1 (ft) 24a. For All Wells: Original form to-Division of Water Resources (DWR), 0
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter: Y:� (in)Bit Off: ( .06n 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: IN 744 Irr' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the Is
(i.e.auge,rotary,cable,direct push,etc.) • county environmental health department of the county where installed
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FOR WATER RIPPLY WELLS ONLY: 24d.For Water Wells_producing over 100,000 GPD: Copy to DWR,CCPCUA s
�.S i Permit Program,1611 MSC,Raleigh,NC 27699-1611 W
13a.Yield(gpm) Method of test: 4 P „ 1
70% hth oZ •Date Site Visited: 39�-G 4,
. 13b.Disinfection type: Amount:23 Site Visited By: L,',8 1
Form GW-I_ -— - __-- No Carglina Department of Environmental Quality.Division of Water Resources Revised 6-6-2018
Price: —I --- - -- -.