GW1--07700_Well Construction - GW1_20231122

WELL'CONSTRUCTION RECORD (GW-1) For Internal Use Only: t
IT
1.Well Contractor Info1 on: /
CYd(j•e1...�+ iy-"tive Gl)e ;~0.14cNWATEIIZONES'�uu:?,,,M7"._%i:::ii��si...=...__`?.t< ...l",�.. ''..t'..:1. e..%; 7 -
Well ContactorName / FROM TO DESCRIPTION CC
3V3 '— A gys ft 3-0 9-4 e"�
l/ ft ,d ft 1
NC Well Contractor Certification Number
IRS::O17T'ESt':CAiSING:(fdicmiilti=case"d;4JeILi):ORI';INERi(if:a'p llcshle)��_._"__:U�'.'+-�",
Yadkin Well Company, Inc. FROM TO DIAMETER I'TmCI SS MATERIAL
Company Name 1 ft. qg ft /`� .5 in. �`j) a I I p u L
r.
�j ® u t16S1NIFP,CASING'ORt:TUBING:(gce'atliermFal+.clvol'sed'7oap)L;-"+'� __- _-
2.Well Construction Permit 4: P�W�. ZCYZ 30 T FROM TO DIAMETER _ THICKNESS MATERIAL^�
List all applicable well construction permits(ie.UIC,Comity,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: Zi :SCREE .� :_ '__"__—-._r__ `-z.__"`M!__.
FROM TO DIAMETER• SLOT SIZE MUCHNESS MATERIAL
°Agricultural ❑MunicipailPublic ft. ft. in..
❑Geothermal(Heating/Cooling Supply) ItilZdential Water Supply(single) ft ft in.
❑Industrial/Commercial • ❑Residential Water Supply(shared) ,;187GROUTI-`- __�W_— -tiJ V_7_____—_-_—_—_________.
❑Irrigation OWel(s>100,000 GPD FROM TO _MATERIAL / EMPLA METROD&AMOUNT
Non-Water Supply Well: b ft ) t/ ft geolow [I;a 9S �y 1� /h p/EC-�
°Monitoring ❑Recovery ft l ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _ _
DAquifer Storage ❑Salmi Barrier is19:`.SANDIGRrAS'EI§PACE(ifapplicable) .__ � =s
q g Recovery ty FROM TO MATERIAL EMPLACEMENTMETHOD- ~
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer r220;DItlIDING1AG:(a"tt4cL�ditianal'sheeta ifnecessary)- -.7"`-"`--
❑Geothermal(Heating/Coo. Re ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rack type grain size,eta)
Date Well Started t - .; ¢ � p 0 ft Zs ft. Ste, f. ¢ Z.ofoS e 5 +6z^-'�.-
4.Date Well(s)Completed: �3 Wen m# � Z BJ C I ft "
`mil ' �� L.t.y.ey:s/ , r,...lC® G 1 /5 .�'^
Phone#: 2.7� C2,e m.a!®6 -25 ft. tg ft
f�, y
Sa Well Location: ' esd ly l lG," •
Inert,- Lt,s � oney imli, of/�, .!47t h Ct t.y /tidy
Facility/OwnerName Facility ID#(if applicable) (09- ft Lf a Pft €/S l 1.(r,t-e,s• ��y/ I1A-A(4.y y&f
62i l�q .`$ SL�c, i1. ft I �^ft ii��✓✓ I .
Physical Address,City,andrZip f2$Ag ft. ft - -__ _
.per - -. _----•---- - �;-_ -_::: .._.`�1`1
�l�l�l� �21:RRMARXRw...`' ._..._._.�:..,----"- --�
County . Parcel Identification No.(PIN) N O V 2 2 L U 1 J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(ifwellfield,one laUlongis sufficient) 22.Certify! - '•
lion: �s..,..,. . ,:_, :::,.. .. ;;-J i�: :i
3c „ 3 74 N 3nr.1 z• }.FcrQ W L 9 a
�' S.yr: • of Certified Well Contractor Date
6.Is(are)the well(s):`�7Permanent or 0 "..porary
. B igning this fonn,Thereby cent Jy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Imo ' ISA NCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out mown 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 C
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. 14.
drilled: I 24.SUBMITTAL INSTRUCTIONS t31
9.Total well depth below land surface: 6/9 a (ft.) Submit this GW-1 within 30 days of well completion per the following: W
For multiple wells list all depths if different(example-3Q200'mid 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR), -110.Static water level below top of casing: ® (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 t'
If water level is above casing,use"+" / y�
11.BorehoIe diameter: (in.)Bit ff: 6�, V l ' 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 9,
Program,1636 MSC,Raleigh,NC 27699-1636
1
12.Well construction method: 4 iv. D Y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA N
13a.Yield(gpm)
1
hth
Method of test: A t o4'i e'Permit Program,1611 MSC,Raleigh,NC 27699-1611 W
. 0,, �� a r4
70% Date Site Visited: "-i' 9o- 3 U P
. 13b.Disinfection type: Amount: ii OZ Site Visited By: fit
_ Form GW-1 ________- _North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018