GW1--07497_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contracto�Inf_ormation: `` _ I '
3e 71 .e S HGi.i 1 e141 WATEZt'ZONES 1?.._a >;`:r:-Z.I:"c. 11'ffs.F.1-2.3,`:Z1 -_": .. :
Well Contractor Name FROM TO DESCRIPTION
A� I .sSt ft. r 3.k3f. Spn!11; 60- gOUP- 3 • .spi
ft I l ^
NC Well Contractor Certification Number „.15 0 ':CASING`(aiiiiniti=cased46114:OR'L•INER":ap'lirahli•)e`_T�..iZ- a.
Yadkin Well Company, Inc. FROM 7 DIAMET TMC fs MAx AL • r-
• ft f ftim / / r—
Company Name ( .r_�,_��.._
0 s q i16. 'CASTING:OR=TOEING:taitlie fnli cldlid:aoir . _ _.... !:................
2.Well Construction Permit#: �1 FROM TO DIAMETER THIQINFSS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) +1 ft 1 2- ft 6 1/5 in. f�.2/'0 , s��.,
3.Well Use(check well use): I' ft in. 1®
Water Supply Well: ;=17:SCRF3EN. ' —7..:...-_r = =�_"y::::: ~;
FROM' TOt� D SLOTS THI S
78TERIAL
❑Agricultinal ❑Municipal/Public ft ft m
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) �ft. ft in.
❑Indust ial/Commercial esidential Water Supply(shared) -1s GROUT2.= -7-:: __'- -- .,__-�_.----
---__-___-_._-_--_
❑Inigation ❑Wells>100,000 GPD. FROM TO MATERIAL EMeLACEh1E T METHOD&AMOUNT
Non-Water Supply Well: 0 ft'
21 it, in (i 1 pC s� ,,A.� /l o c,a 5
OMonitoring ,. ORecevery_, ft. ft lS J ./
Injection Well: --1:r ; _ ;, ;) ..., �.) ft. ft.
❑Aquifer Recharge ,-Y "' '''1 OGroundwaterRemediation _ __.___ _____
❑Aquifer Storage and Recoveeg0\J OO yBarrier i=FR:SAM RTOELYACIV(MAijill abley.":1__ _ _..-__._ __,- .--__. .
iV J FROM TO ' MATERIAL EMPLACI TMETHOD
❑Aquifer Test ❑Stormwater Drainage ft J
OExperimental Technology3;- C n; q$Subsidence Control ft, ft '
.' . 0 Geothermal(Closed Loop) ' `' -❑Tracer 720 DR11;'iliG'IAG:(ittach additionaLaheeta ffnecnsttry)="
' ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks). FROM xo D&SCRIPTION(color,Lardaess,soNroek type grain size etc.)
Date Well Starte( RV-,d• 23 0ft cb•• ft. : I
4.Date,Well(s)Completed:11-Z"11 well m#44P-• k 1 7 'Cic f- D * rt l L rt9 G l� �M t
5a.Well Location: Phone
�.l� Phhone#: • /O3" 2/s i C'l,�( • 5 O ft I.JC y-, (S.114- y �o y
•
se ;/V C C ITS�y �9
� . �®"(//t/D 1�2 / �ft® /® t tl� tif41114,) /., 1,
/ Q/L ' floe a.
Facility/Owner Name Facility]D#(if applicable) ft- ft ( -
!' 1 \4 V.J ` ft ft
�� .
Physical Address,City,and Zip _ y/,[ @/1 I ft. ft
County ' ' Parcel Identification No.(PIN) 'd`^t 2-S/s A UIt7 Fn i ®" 1 441 flry,
0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well geld,one lat/long is suffieient) , -. 22.Certification: _
6 • N 1., 6 1 w •
3�. .'. • tilZ ---- tit- a._)i
6.Is(are)the well(s): ermanent or ❑Temporary. .• - Signature of Ceitifie ell Contractor Date
• By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy 04
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 G W 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• drilled: 24.SUBMTTTAI�INSTRUCTIONS
9.Total well depth below land surface: 7 0 (ft.) �
For multiple wells list all depths ifdifferent(example-3(200'and a 100) Submit this GW-1 within 30 days of Well'completion per the following:
p� 24a. For All Wells: Original form to Division of Water Resources (DWR),
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''+" ...
• 24b.For Injection Wells:Copy to DWI,Underground Injection Control(TUC) t
11.Borehole diameter: (in.)(31t Off: `�j Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a e/ f/9 i-tfi P�y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the sul
(i.e.auger,rotary,cable,directpush,etc.) f county environmental health department of the county where installed CP
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWI,CCPCUA
a- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) , Method of test: r/ CAA o
o h Date Site Visited: £ '`l= 23 - I .
2.3
13b.Disinfection type: 7�/o fh Amount: 3 Oz Site Visited By: V
I '
Form GW-I North Carolina D_ epartment ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018
Price: i • , _- -- =- ._- -- -- - .:_ _- - - -- -- ---