GW1--07947_Well Construction - GW1_20231208

. JC,CONSTRUCTION RECORD (GW-1) For Internal Use Only: AI
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1.Well Contractor Information: ( I `v
ra,'rk 93 DiiwATER-ZONES 1>i. :i:V..1<?'7 I.:i;,':-,.._ ,c".C, :TZ - ...._.....ir' ;r; ;:f AT -
We11Con1tactorNam FROM TO • y DESCRIPTION
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NC Well Contractor Certification Number iISrODTER:CASING'(ftiimrilti=cased veIs):ORLTNF.R"(ifapIieable)L j"`'.iCv';::Ta +O
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name - �`t4ipV- 92.4A0 `t1..6iINNERCASING:OR.ITIBING:(Qeotfiei`mal¢lo9ed=loop)b '"��_'7.:tMtV:' rn
2.Well Construction Permit#: i 3 gb FROM TO DIAMETER THICKINESS MATERIAL %'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ' ! ft 1 j ft J 4,IsPc in. ems' Pe
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3.Well Use(check well use): ft �7 it q� In `� C)
ago. ,.-_ -, ._.��`_ ^ - —_.:f___� '-"r r u;
Water Supply Well: FROM TO DIAMETER SLOT St7F THICKNESS MATERIAL v
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) gKesidential Water Supply(single) ft ft in. G
❑lndustrial/Commercial ❑Residential Water Supply(shared) :18 GROUiL... -" __"._- _�`T�`� _i=� 1
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL f EMPLACEMENT METHOD&AMOUNT •Ab-
Non-Water Supply Well: ® ft. 0%1 'ft 143ea',%/P, 0 fig, CJa
❑Monitoring ❑Recovery ft. ft. p
Injection Well: cr-
ft. ft
❑Aquifer Recharge .❑Groundwater Remediation
i A.9'S ND/G AVEDPACK'Cf a cable)---- _-- ..:,,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer Ca0 DRILPYIVGLOG:(iittachaadittbiiillhe'etsifiieeess'ary)'=_____= ? --+
FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) v
Date Well Started //~�-7').S 0 ft � o� ft , !o•L iL fit ,e g or e-4.
4.Date Well(s)Completed: //.g'w�%)7 Well ID#Phone#: , V. , 'o9 el6 ft i, f' /4 ROC Le eta'$ E
Ff,' s-21U-S qpar 7 0
/ L,ete../ 'csv1C
5a,Well Location: � Wag tt��g.
n elue,+ Silly P'4frk 1 , -
Facility/ Name Facility ID#(if applicable) ft ft ^':l,.r l' ]. I
GIC3 14,,8r //�� �h :.W k, ft ft ^ )
l^r �t[ 0�/ l �]A1� ft. ft l i=:� � � ��L J
Physical Address,City,and Zip ,W6W S` _ --.
County Parcel Identification No.(PIN) Dvvvy� ,4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one latlloag is sufficient) •
22.Certification:
,:c 9 q3- Z t1C N '/, }S1 Fr`t2m W 2yAJ'/i.LJ/1 -A 3
6.Is(are)the well(s): nireermanent or OTemporary Sig ere of C ed Well Contractor Date
� By signing this form,'hereby certify that the.well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or .n o 1SA NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repai,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark'section or on the back of this fans. .
23.Site diagram or additional well details: al
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 y� .
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. •Y
drilled: ! 24.SUBMPLTAL INSTRUCTIONS
9.Total well depth below land surface: ® (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) 3
10.Static water level below top of casing: . m. (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), F—•
If water level is above casing,use"+" Infounation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: cut)Bit,Off: 6,0/O 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC) E
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ®gf• "/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 7
. (i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD: Copy to DWR,CCPCUA ...t
13a.Yield(gpm) �® Method of test: ��d" 'Aar
/�d Permit Program,1611 MSC,Raleigh,NC 27699-1611 (v
70 o I' Date Site Visited: .?/3;2-3
0 /
13b.Disinfection type: huh Amount:_ 6� OZ Site Visited By: Q,�i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource' Revised 6-6-2018
Price:_