GW1--07950_Well Construction - GW1_20231208

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Ili�.%y-'i tL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
-3-.8 ch,t ' N tY p Y u� ,.3 `J.4I.WA1 ZONES ',1.12 L.1
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4.
FROM TO DESCRIPTION
Well Contractor Name
9 57et'A /is ft- /Po ft ,7 jt®���'/� 3®7,°, p
/91 ft �t ft J 4!".-$i. to tot
NC Well Contractor CertificatroeNumher 13 OIITEI CASING:(for`:multi-c'ased:we1G)'OR7 (iEip Tic'.-hie).:11 7),,,,,.._•,-t_ 4,1�:e C
Yadkin Well Company, Inc. FROM TO DIAMETER THXQKNTSS MATERIAL
• ft. ft in.
Company Name ia. Qdag'.. Y( Z(�
_Q ®
::_:l'6IIVNEIZCASINGbR:TUBING(geot3iermal.:cloaed3o'op) 't" i" i:ia::f:j ;
2.Well Construction Permit#: 4,3 2 G 0-- FROM TO DIAMETER _THICKNESS MATERIAL
_.List all applicable well construction perm s(i.e.UIC,County,State,Variance,etc.) _qa}./ ft. t6.1 ft 4 r j.a n' sox-.).9 pied..
3.Well Use(check well use): ft. ft /� in. 4
Water Supply Well: tii;1:rSCIZE$?.`f• =�+•� .__ _, __ -� rst•
FROM TO -DIAMETER fi.SLOTSIZE THICKNESS MATERIAL ^-
❑Agricultural ❑Muaicipal/Pnblic ft ft in. .....'
❑Geothermal (Heating/Cooling Supply) residential Water Supply(single) ft ft M. .r.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18 GROBT;=v -;-w.' "- -,.=- »= _E
❑Iaigation DWe(s>100,000 GPD FROM TO MATERraL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 4 0-'ft. mos.ehos, a' I ,
❑Monitoring ❑Recovery ft ft F
Injection Well: ft ft
❑Aquifer Recharge OGroundwater Remediation _.
i:`:19:S`bND/GRAv.vaiiiACK(0faisplic`ablle)�_: '.",.1_
:Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Ri22-LACEI1ENTNIETHOD • •
DAquifer Test ❑StomiwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. , ft
❑Geothermal(Closed Loop) OTracer "a 0:DRIL't4VGT:OG'(ittacl:Mi itio`na'1a7reetaifnecnsary)`_" .....:2-
_
❑Geothermal(Heating/Coolin Retum) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sailltoek type Praia u se etc.)• w
Date Well Started //. i@-'Zee 0 I �. �
4.Date Well(s)Completed: ///®° :3'Well ID#Al 4'r-9 10 q ft ". .5-'ft
"-eif5a WeIlLocation: Phone#: Q-1eS".C®'9�4(� 7.s- ft j�Df¢t se® t vea `to 4, ®e,p®
3 ea PM C c,�e Pr Ti� ./ ft. 2P- jt' in ti .Stt ° : °�L d it'. . A
Facility/Owner Name Facility Ba#(if ilicable) ft ft '-°: . ?t r '-5-1
CZCo SiA0Ay Err. .il ear cfn.i ft ft ..: . .4-...,!Li
tD Physical Address,City,and Zip • ft ft C. U 8 Zne_3 _
��C P'�:•�' fI MMa t tz.mpMA"RRR....�,,.__ `.._.- i�,a�,,.��.. ij. , Y,_
z`o
' County Parcel Identification No.(PIN) ? PISegtie '' 445e4 S:a'x . ' +ipf,2 j ecolRn� b
titaP 5b.Latitude and Iongitude indegrees/minntes/seconds or decimal degrees: pe''►0�u
AU.I R e+ 44 /e 4- iT / ®b
(if well field,one iatnong is sufficient) 22.Certification:
55955?.7-4U N -9I.i(30311 W Cr /m0a-)"62-3
6.Is(are)the well(s): permanent or OTemporary Si hrre o ed Well Contractor Date
By signing this form,Ihereby certri fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an misting well: DYes or k(o ISA NCAC 02C.0100 or15ANCAC 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-is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SuBl'AT TAL INSTRUCTIONS
9.Total well depth below land surface: ` -...2.... (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
10.Static water level below top of casing: ` 0 . , s 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: C (n.)Bit Off: 4.0evo 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a, �Ave, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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
13a.Yield(gpm) q� Method of test: . dam AII.0 Tzry
Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: 7 -f
. 13b.Disinfection type: Amount: 4 y Oz /Site Visited By: DRS I `e
, 1 ttts
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018