GW1--07958_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD(GVV41 For'InternalUse Only:
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_ 1.Well Contractor Information: 6
- 041 V F-' I Ps`(M ! `1 I l;;Y. fi4 WATER`ZONE.V. •-DPsc.RIrT R:- �c:za.=•1',i :.'tin;` .1,l'A,'> 4 -
We11 Contractor Name FROM "` T0�
= ON
--, [/ ' 0 LP' . 's?i3 f. (t(aly !fuc.(•Spe:- rA�yk` V •
Nc we/!i C I '3',s(i ft' /i ft A a 1�.$0 pi. .- vi tier..-
' ertificationNumher ,15:;U'01T3zG'}1S1NG'(fo4`•:mfilti cssedWillii:ORx3NE1l�(ifsp` cable)=" ;s�',':..T a
Yadkin Well Company,Inc, ' FROM -To- DIAMETER THICKNESS MATERIAL
- ft it 1n.
` Company an Name
� - •s1•6VINER'CASING:ORIBBING(ge itliesmaldosed=to"op) s"''.��`,:" '7` `-aiVal
Z.Well CorstrgetibnP,ermit#: q ! '1 FROM TO DIAMETER THICKNESS MATERIAL
List ail applicable cons/ructionpermits(r.e.-UIC County,Stale.Vanimce,eti.) ft: ft . in.
3.Well Use(check well use): ft.• ,: ft in.
Water Supply Well: OM TO~.' DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public St -- ft. in.
. , ❑Geothermal(Heating/Cooling Supply) Aesidentjal Water Supply(single) , ft ',ft., in.
❑lndustrial/Commerciel, ,[7Residential'Water'Supply'(shared) 4;18:1GROUT:I- -;:„:` ,� — _-----,
' ❑lnigation ❑Wells>100,000tGPD FROM TO MATERIAL EM?LACEMENTMETHOD&AMOIINr
Non-Water SupplyWell f. ' ft. /( y Led co ,
' NC °' `�'
❑Monitoring ❑Recov ft ft i
InjectionWell• _ _ - ft ft
❑Aquifer Recharge ❑GroundwaterRemediation r - i,
jw19:'SAND1GRAQ BPACIMitpliealile), _ 1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM - - TO ' MATERIAL EMPLACEMENT METHOD • - '
DAquiferTest .DStormwaterDrainage ft. ;.: ft. i'
DIHXperimental Technology ❑Subsidence Control ft, ' ft I -
❑Geothermal(Closed'Le0p) OTracer ±-26:DRI,t iG'EOG;(s`tii aiiitiona Ti kilt if'rieceisuy):`~, _Ill
❑Geothermal(Heating/CoolingRetum), 'OOther(explain under#21 Remarks)_ PROM To DESCRIPTION(ester.hardness,soil/rock typo antra du,eta.)
Date'Well Started �+� 9 00 ft •'d,.(,fit o'F-�-- flock
4.,Date,Well(s)Completed:1-l--1 f-23 WennID# p�27 ft. ft ,
5a.Well.Location: ;Phone'#:g;);T,4�3,.gs , ft; ft
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F /Owner Name - ( Faciitylp#,(ifspplicable) ft ft
11: S; a fat,. Dr" F1 a+wft . .
PhysicaLAddress,(5ty and Zip f. ft. Ine3rmag! •n P .,,,,;n<3 t «
County I'LL• Pared ldentificationNo.,(PIN) ,,
56:'Latitude and longitude in degrees/minutes/seconds or decimal
(if well field,one let/long is sufcient) ,'Certification: u
3f_ 1 gig 4144 N k13/,?,103 - w r1—rCszi•
6.Is(are).the well(s): ermanent or, '❑Temporary Bna fCeriifledwellContra ri. Date
By signing this form,Ihereby certify that the wells)was(were)constructed in accordance with {
7.Is this a repair to an existing well: pees or L'INo t- pp t� 15ANCAC.02C:0100 or 13A NCAC 02C.0200 Well Construction Standards and that a copy
Ogg is a repair,fill out known well construction information and explain the natatlrse of t of this record has been provided to the well owner. .
t I repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details: A
8.For Geo obe/DPT or Closed=Loo Geothermal WellsWells!havingthe 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.
drilled: 24.'SUBMTT TA L INSTRUCTIONS
9.Totalwell depth below d surface: Qi G'G (ft.) i
For;muhrple wells list all depths ifdiffoent;(ermeple-,3Q200'and 2Q100) (Submit tins.GW-1`within 30 days of well completion per the following:
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10.Static water level'below topof casing: 7 24a. For All Wells: Original form to Division of Water Resources (DWR),
ing U'® t (D'') `Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
• If water level is above casing,use"+" //'� ,,•
11.Borehole diameter (tS (in.)Bit Off: . •`7 S�t 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 'I--
Program,1636 MSC,Raleigh,NC 27699-1636 .:5
12.Well construction method: _Y 6 tid,4r le 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
. (ie.auger,rotary,cable,hrectpush,etc.) ( county environmental health department of the county where installed ro
FOR.WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
}_ i Permit Program;-1611 MSC,Raleigh,NC 27699-1611
I' 13a Yield(gpm) 1' Method of test: 1 l�• t
70% hth_ ( A 3— 3
Date Site Visited" I¢� a�j° c'
13b.Disinfecton;type: Amount 2 _ OZ Site Visited • V i
• ,- Form GW-I North Carolina Department oflinvironmental Quality-'Division'of Water Resources Revised 6-6-2018
Price: i