GW1--07676_Well Construction - GW1_20231122

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V6'EtII.CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: ? g
ft 4I' 13 to r J.4:.wATERzoNEs.az,:IIN.-: ±l ;:, .. _-.-;:: .-‘,.;-:,:-_-_;,-.7_-__::_),,....,.....-,:.:..�
contractor Name FROM TO .DES�pCRIPTION
Wel(((Con
C. �/� ft. lig ft� ro. S>
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/7.r ft !Mitt •` .10 j P
NC Well Contractor CertificationNumher
'415."OUTER:CASINGVOiiiinlfl=cased.weILSyORIONEt(ifgP-licible).:=:_->"_'=CZP
Yadkin Well Company, Inc. FROM TO DIAMETER I THICKNESS l MATERIAL =
to
Company Name �..k. rg,_�/ _ '1161INNERCASING:OICTIBING:(geotligrmal:clefedadrib)'; �_-
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2.Well Construction Permit#: 3,A Y ... C FROM TO DIAMETER _ TECKNESS ,MATERIAL
List all applicable well construction permits 6..WC, omity,State,Variance,eta) + 0 ft. g 2 ft. ®•YLI m• SiNt n p PVC
3.Well Use(check well use): ft. ft S, in. I` �(d A�tl�
Water Supply WeII: ZI Sir":'' ::2:_`.. ____�_`_`-_7 _ i �
FROM TO DIAMETER : SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑ clpaal `
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft t .., e' ,
❑lndust ial/Commercial ❑Residential Water Supply(shared) f8•GROU.v: ' ____ _ :_ __ __ .. a 2
❑irrigation ❑Wells>100,000GPD FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft Aiti ft. l�sr.4,s t•av) 'ps (rg v117 � i
❑Monitoring - ❑Recovery ft. ft. l +
Injection Well: •
ft. ft •
❑Aquifer Recharge .❑GroundwaterRemediation �_____ _____ __ _._ _. _
j_19'SAND%GRAv1�:1P.ACIC•(itap'plicslile)a.�__ �__ :-- •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' •
DAquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ID Subsidence Control ft. ft .7 /
OGeotherinal(Closed Loop) OTracer ''iZ6cDRI1;LI1VGI:OG`(affach`:adi itionals3eetiifneeessary)'_1_.:_._:-_ :_. __-:
❑Geothermal(Heating/Cooling Return):' 0 Other(explain under#21 Remarks) FROM TO D7CRIPTION(color,hardness,soil/rock typo grata ,etc.)
0 ft. 3 ft. (Jd,
Date Well Started )[iD�- !i g-,�3 /� f �
4.Date Well(s)Completed: /0-i - r.�3 WellmD# •r��f� ' 7 I 3 ft. 70 ft Cubiie,, Sig® L ia,9iii ,� J I®ci
5a.WellLocation Phone#: - L ' -9iG® �0 .rg ft ef,A.n.4 ^.e., -
• f ft.T c Leivc VI�tY
-
,_,_-
ft.
ft.Facility/OwnerName, Facility ID#(if applicable)
39 T g-Juqd CQ4- Itl iNeop irrer olpig ft. ft. NOV 2 2 2023
ft ft
Physical Address,City,'and Zip,
tn;,L;; -;7 •1.- _'i Cr
(it` i21:11.FMA_ulrc:+ 'y_�..._ ::="_.;_.._ �.-_.-�_=_tZ.;1:�2:f _A=2:2- _ ---__.-2
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:
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® zoBid ,N V. 5-0 c:)."' w ® �� id- /k9 3
the well(s): Permanent or ❑Temporary Signature of Certified Well Contrac r.: Date
6.Is(are)
By signing this form,'hereby certify that the well(s)was(were)en strutted in accordance with .-'-'
7.Is this a repair to an existing well: DYes or me RSA NCAC 02C.0100 or RSA NCAC 02C.0200 Well Construction Standards and that a copy C
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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. VP'
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 W
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. W
drilled: i 24.SUBMITTAL INSTRUCTIONS W
9.Total well depth below land surface: (ft) tb
For multiple wells list all depths if different(example-3Q200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
aa 24a. For All Wells: Original form to Division of Water Resources (DWR), 9
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"+"
11.Borehole diameter: C (in.)BIt Off: G o O wi, 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
a Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: P3dIr �vwd ate, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the sb
(i.e.auger,rotary,cable,direct push,etc.) f county environmental health department of the county where installed o
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA W
p 4 Permit Program,1611 MSC,Raleigh,NC 27699-1611 f
13a.Yield(gpm) ,V. , . Method of test: in!ffi' el/f i.i wi v, Yke -•
70% hth a g oZ Date Site Visited: st-2,12.9
. 13b.Disinfection type: Amount: Site Visited By: Q a b ia9 6
Form GW-I r North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018