GW1--07675_Well Construction - GW1_20231122

L CONSTRUCTION RECORD (GW-1) For Internal Use Only: l
1.Well ContractorInformation: 1
.� "'4• P..4w� Lc/9 04r.WA1'Ltt`ZONES'•:: �c,i �I
lll@ :;i;::'_:-.-_;".: :�:^;t.`�,�.:, _.:.:. .-_ .,:2
Well Contractor Name FROM TO DESCRIPTION
• ft. ft
3636A ft ft
NC Well Contractor Certification Number a.15 0UIER'CASING'(fo`i'multi;cased ie110.ORMINEI'.(ir--lic`iblel;-"22,- i
Yadkin Well Company, Inc. FROM TO DIAMETER TBICIINESS MATERIAL
ft. ft. in.
Company Name
=16INNER:CASING:ORTUBING(geitlii:rmal:cl`o'ialaop)'C =� :-''
rd 2.Well Constction Permit#:IL.A AA P-Cif G V 9 i - 2. 2 2 FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: r ='S r'•-_-__ --- . . _
FROM TO DIAMETER SLOT 4I7F -THICKNESS MATERIAL
❑Agricultural ❑Mtmicipa]/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) -
ft Ft in.
❑IndustriaUConmmercial ❑Residential Water Supply(shared) 1 �
❑Ir igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MOU PLAENT METHOD
Non-Water Supply Well: ft -ft - .__ , .,i i i;{- ' i l
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft NO V 9 O 1
DAquifer Recharge .❑Groundwater Remediation
DAquifer ❑Salmi Barrier r-19:.SAND/GRAVELPACIC'(tilipli'cable)��.__,w. _::! .:-;_ __.;-`_, ,�...... .
rl o Recovery ty- FROM TO MATERIAL EMPLACEMENT METHOD .
DAquifer Test ❑StormwaterDrainage ft ft - -
❑Expetimental Technology ❑Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) ❑Tracer ;20I13111/;L IGI;O0(atf'scli'dditionelslata ifneceuary) __::_� ��Y
❑Geothermallose(Heating/CoolingReturn) ❑Other FROM TO DESCRIPTION(color,hardness,sotrock type,grain size,etc.)
(explain under#21 Remarks)
Date Well Started H- Z- ZS /103f`' 2o®3ftc- 6s44/94, '
4.Date Well(s)Completed: I I- ?.-a3 Well Pr S-3 q ft ft
5a.Well Location: Phone#: 3 r a - 6/(� fc. ft 6,:r3: cool A
1 .,ch..
®�� t.4s ft. ft i Lf�® /940
.Facility/Owner Name /� Facility lD#(if applicable) ft ft .r®JJry i� ...red/ s ha/ PP f
it ft /
PhysicalA+ddress,City,and Zip ft. ft
County .. Parcel Identification No.(PIN) Jf l I";t k 1. J '-Q,Q 4- ' T 24;3 3 e 4i44a3 B ` •-412 CO 0 K1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iat/long is sufficient) 22.Certification:
• 3C® //> •3 N g07' 4it7d 3,38 w .
7"4.-
6.Is(are)the well(s): li#Permanent or ❑Temporary Signature of Certified Well Contractor Date
/` By signing this farm,Ihereby certify that the well(s)was(were)constructed to accordrince with
7.Is this a repair to an existing well: ❑ �_
Yes or ego 15A NCAC 02C.0100 or 15ANCAC 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 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: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 02 C)a 3 (ft.)
For multiple wells list all depths if different(example-3Qa 200'and 2©100)' Submit this GW-1 within 30 days of well completion per the following:
10.Static water Ievel below top of casing: (.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaren level is above casing use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ly
/'9 (in.)Bjj;Off; �• 8®.�g2
`.- 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
{� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 06/1. P pT 27-tr-t 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) c unty environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: st 0 4 i P4, A j A 7t 7 +ForWater Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m �d ' Program,1 11 MSC,Raleigh,NC 27699-1611
(gp ) Method of test: fl/ Ct/f
sv
70% hth Date Site Visited: /o-'26-6-
13b.Disinfection type: Amount: OZ Site Visited By: OTC -
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources __ Revised 6-6-2018