GW1--07670_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 2
Co
1.Well Contractor Infoorrmation::
Aft. r (14
U ` 1 P'" i k! c .A/4.. :1%t:WATE$:`7ANESi:'_;i:Tf i'U't r::_.. ,•1.?,^=...:?i �,.�:. _.:t:. .�.'r,:-,c .1
Well Contractor Name FROM TO DESCRIPTION
1
9
ft. .• ft
NC Well Contractor Certification Number '15FOUTER"CASING'(farmtilti=Efts'edlivelti):ORt7I,VEICCif:$P '611) -':Q_
. Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. • in.
CompanyName 6r]NNEICCASING'.OR'TQBING eotSeimireldi liiii =r;, :
1 ( P)i - -
2.Well Construction Permit#: _FROM TO DIAMETER THICKNESS MATERAA`.
List all applicable well construction permits(i.e.U1C County,State,Variance,etc) kt ft. Li 1 ft ;tut 126-m. cDa L 1 pvc
3.Well Use(check well use): ft. ft. in '
---
Water Supply Well: DIAMETER
i :.S atZt:-"_`.-----_� - -:�_�_ =v
FROM TO SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in:
❑Geothermal(Heating/Cooling Supply) ❑�R,//esidential Water Supply(single) ft 4 ft. in.
❑Industrial/Commercial li esidential Water Supply(shared)•
_— — -
❑lnigation ❑Wells>100,000 GPD FROM TO MATERIAL // EMPLACEhiENTMETHOD&AMOIINT
V ft. ..: ft ,- �c �,)f '`pI6A(ie4
Non-water Supply Well: a/ Jr �q �.
❑Monitoring ❑Recovery ft. ft.
Injection Well: - .
ft. ft.
❑Aquifer Recharge DGroundwater Remediation
i519:.SAND/(RAVETIPACE{•Cxf.uppbcillle)I---- -�._---—=----- -'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 2tliDR1C R$GZOG:(a-ttiich`nddifigrial'slie'e'fs`:ifneeess`siy);:=__—`----" -
t FROM TO DESCRIPTION(color,hardness,soillrack type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) !� ft ft. of t r lJ
Date Well Started 1'0- '�- .S .5
4.Date Well(s)Completed:r(/;,�.re-23 � Cl
Well 1D# Ion"yl? '�-s- ft. t ft. ,,sit-. 6j,-.,e� ,✓6-clli 4e '
5a.Well Location:p� Phone <#: 3 .. 6�C-/4 R $,� it. 3®� ft fY ) ✓ e : - -��,i 4-,e
�✓o[0'R 4 w�/� (✓ l ft ft. -
L'
Facili�typ/OwnerName' Facility ID#(if applicable) ft. ft. 4, •
' " - . a.212 E.[AG ssiLQ1f d'J aht0, 6r��� ft ft. NOV 2 2 2023
Physical Address,City,and Zip ft. - ft.
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: •
Z C n 661'if N a0, S ..3 .3, i t w cyyta.4-7d c , , - . 10_2.5-,-. 31.r.,::,.,:.
ct;A-u-e - .
6.Is(are)the well(s): liFYermauent or ❑Temporary Signature of Certified Well Contractor Date
By signingthisform,Thereby cerdfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 154 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 remarlr•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.
drilled: 49 ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -�� (ft.) (J
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following: U,j
Wyk 24a. For All Wells: Original form to Division of Water Resources (DWR), G
10.Static water level below top of casing: • (✓ O Information Processing Unit,1.617..MSC,Raleigh,NC 27699-1617 --•
Ifwater level is above casing,use"+"11.Borehole diameter: ( (in.)Bit Off: 6` 1 )4 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
r �-. Program,1636 MSC,Raleigh,NC 27699-1636 ,
12.Well construction method: A0 t "1C7 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
1
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA tLl
i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ‘Ci Method of test: t rto.,e a. W
70% hth Oz Date Site Visited: 10-j,3e 2 a��' ,
. 13b.Disinfection type: Amount: Site Visited By: 1) Tt i •
Form GW-1 -,_North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018