GW1--07699_Well Construction - GW1_20231122

1ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: It
1.Well Contractor Information: C .
CV'pctSre- , V -etrCs.0-$: �. 0.4::WATER`ZONES T:S'Solf,i; 'I T::'s::_, 1-.-,i,..::�;..�-... .X..; .•... . = •
Well Contractor Name I / FROM _ TO DEDESCRIPTIONtf)
S q •
its ft ' 1A/�1 ft 50 c„,p
�J .6jj n _'DA.ft. 3 6 (.P`a'` R.
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NC Well Contractor Certification Number
u15?OU1CC�ASINGV6Fii iilti-casenielICORIIIERICdap lle`aile)t "` i_,;,.7:_
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Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESs
4 ft. I S ft. 4,4 2.5 in. R
Company Name M �� TUT_® �q� '?l ER;.CASING OR.TOBING:C�eothaimal.clased7oop : __7__..�:. 7a;7iii
2.Well Construction Permit#:PR iN L 2.01 1®® I®.T G FROM TO _DIAMETER THICKNESS MATERIAL
,71
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: �:.
FROM TO DIAMETER SLOT SIM THICKNESS MATERIAL ,�.
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [:3f�esidential Water Supply(single) ft ft in. .
❑lndustrial/Commercial ❑Residential Water Supply(shared) acGs. --- ---- . _.-____.___.___
❑Irrigation ❑Wells>100,000 GPD FROM TO TERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft, ft e 1l f(i p I1rtJ k (� Mat
le-- O
• ❑Monitoring ❑Recovery • ft. ft 7r r
Injection Well: '
ft. ft.
❑Aquifer Recharge .0 Groundwater Remediation
1%19 SAND/GRAVS'+L PACIC(if'ipplicable)::_=-_-___2_._.:=___ _ - ..
❑Aquifer Storage and Recovery ❑SatinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD •
❑Aquifer Test ❑StomswaterDrainage ft. ft.
❑Experimental Technology CI Subsidence Control ft. ft •
❑Geothermal(Closed Loop) ❑Tracer G20:DR)T,T'1VGGI:OG.(aifiair a'ditiaria`lsbe"etii:iEueceesary):__
❑Geothermal(Heating/Coo- gRe ❑Other(explain under#21 Remarks)
FROM TO DESCRIPTIONN(�olor,hardness,soillracictype size etc.)
Date Well Started Q �'c�Q, V ft 6 ft. �a i t 4- J e)be e. 5 k-e
4.Date Well(s)Completed: 23 Well#I1 / ! 66 �' t'1 y-cv� lei C t� �>-®t 0�G.
5a.Well Location: • Phone#q 3G �‘��✓''2 qL( ft. 11' ft t a[ 144e. f
�g// GL1Z f�
v��e •E-.Emily /��i' r� J G� �� ft. ��� ft c9e• , L-e, (Veer?.j/P r
' Facility/Ownef Name l Facility ID#(if applicable) ft ft'
•
39g0 aplov Sv,A, ad Side. Re.cG A ft ft
Physical Addressf city,and p ft. ft. }
�t�Vvc, G2.i Iiutvre�Iug_�.. __r_.- - _�= �..:.IN.():til�2�i:tl1 a.1
•
County Parcel Identification No.(PIN)
'Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Iti'" J J(if well field,one laNlong is sufficient) i 22.Certific..on: /
SC, 296i(- N r0, V7TO ' W ` /,________.,7 Oe /a®,93
6.Is(are)the well(s): Permanent or ❑Temporary r�. i e of Certified Well Contractor ate
• 1 sig ingthisform,I hereby certi&that the well(s)was(were)construe:edin accordance with
7.Is this a repair to an existing well: ❑Yes or !Rill ISA NCAC 02C.0100 or 15A 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 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. ,C
drilled: I 24.SUBMITTAL INSTRUCTIONS 0,
9.Total well depth below land surface: �g (ft-) P
For multiple wells list all depths if different(example-3@200'and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
• ,• 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)Blt Off: t 7 t( 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 .
00�� t
12.Well construction method: �C r s ® 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health departmeiat of the county where installed
K.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
A,(�,i(.. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ®® Method of test: ii t ('e e( s a d�•�,,�„- Z
70% hth oz Date Site Visited: �-/ ' �3 t §,ram.
. 13b.Disinfection type: __ Amount: Site Visited By: p I
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018 \ "