GW1--07531_Well Construction - GW1_20231120

' %�6LL,CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Well` ontractor Information:
® 0 E. 4_WA1'i. ZONES-W " '-1fZP.2. i' '.,:',M . .,3z.
J1%:.t"L.'Y-i�;..�%il.; }.��:;ex"L•.=�i^`sn`.':=i:::� ,t
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FROM TO DESCRIPTION
Well Contractor jName�q I
�`c 4,L� " ft. ' ft � ��
ft. it •
I. •
NC Well Contractor Certification Number ,',x5?OIITEIC.CASING'(for'multi=Based<weIICORLMFIV(ifir'llr ilel. i:, ' -
Yadkin Well Company, Inc. FROM TO DIAMETER THICI SS 1 MATERIAL
ft. ft. in.
Company Name '116SIliNER:CASINGORRTUBING:` eother'nial:diiied:loop)^.,�f-'' _ :~_.'L t
0 /.�.� .E..
2.Well Construction Permit#: FROM TO DIAMETER TRIMNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc) 4/ ft 11 ft. %r/�cin. S/�A9 •1[9 f a
ft. ft. ( in.
3.Well Use(check well use): ar _ ��y _^^��__— __ ._
3:/.liJSI';tll`!L'1.\!a: 7t -.w.:.-._L�...- ____.::: _-.-..may.-`.....,
• Water Supply Well: - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑MunicipaU
/ Public ft. - ft. in-
0 Geothermal(Heating/Cooling Supply) I .esidential Water Supply(single) ft ft in-
❑lndustrial/Commercial ❑Residential Water Supply(shared) 11e..676 arc-1-::T: --,----=-=. =°` - ----
❑lnigation ❑Wells>100,000 GPD FROM TO MATERI"A'L� EMPLACEMENr METHOD&AMOUNT
Non-Water Supply Well: 6 ft. A• ft , e/d-r�a.;0.3 8d
❑Monitoring ❑Recovery ,( ft ®. fL /) P5h"y � ,j�
Injection Well: ft. g - ��""
❑Aquifer Recharge .❑Groundwater Remediation Y_ n__� �_ '
Ii:I9 SAND1GRAVRLPACK(ifapplicalile)::.. ._.���.y :
❑Aquifer Storage and Recovery ❑SatinityBarrier FROM TO MATERIAL - EMPLACEMENT METHOD •-
❑Aquifer Test ❑Stornwater Drainage ft. ft
❑Experimental Technology OSubsidence Control ft: ft •
❑Geothermal(Closed Loop) . ❑Tracer 201DRUABGI:OG1(attschtad'ditioria"T:s1e'ets finecelsaip')..= =;_.`=
FROM -' 'TO - DESCRIPTION(color,hardness,sea/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft aft
Date Well Started 10 4'® a • . .®i . d=.S�'�y
4.Date Well(s)Completed: /�b38 Well Mt/AA P 1 i Y -7; f. ,, 'f ft. rh jaPi.,�.a pl ' Ara A-47
5a WeIlLocation: Phon L e#: 7O 7Yo- S'62Z. ft. ft. 1r'
iPel,
ft •ft • �; y.-,r }
'.9�. ^' .:� � :`'iv . •
. o®ems MOB �,t ,�
Facility/OwnerN ft.. {t
ame Facility ID#(if applicable) 1, .
ft.' ft. NOV'? 9 2Q23. •
Physical Address,City,and Zip it fL f 2] IIElVrARKR;•" r a __. �._ : __ ' Sm_ i .
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County • Parcel Identification No.(PIN) • _ . ,
{ .
. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - . • •
(if well field,one lat/long is sufficient) .22.Certification: '
h
�� e 4 ci2' N F�a 07 V-3 W ;-' /
6.Is(are)the well(s): Ehermanent or OTemporary
Si;.-;> ofCertifi ' ell Con "tor . Date
By signing this form,I hereby cerh fy that the well(s)was(were)constructed in accordance with
7:Is this a repair to an existing well: DYes or MPo ISA NCAC 02C.0100 or ISA 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 bf this form. 23.Site diagram or additional well details: a)
You may use the back of this page to provide additional well construction info (3J
8.For Geoprobe/DPT or CIosed-Loop Geothermal Wells having the same
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.
drilled: ® a
24.SUBMITTAL INSTRUCTIONS
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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 ifdifferent(example-3Q200'and 2@100) 1
24a. For All Wells: Original form to Division of Water Resources (DWR), -
10.Static water level below top of casing: ® e (ft.) Information processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: ( •)131t Off: ,B� � Program,1636 MSC,'Raleigh,NC 27699-1636'
12.Well construction method: /d®T SAril 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 —r
05
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA y
Permit Program,1611 MSC,Raleigh,NC 27699-1611 r. � Q)
13a.Yield(gpm) t. Method of test: A�i� � Date Site Visited: 9- h- 3 _
o
13b.Disinfection type: 70/0 hth Amount: /?`' OZ Site Visited By: 6 =
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6 2018