GW1--08007_Well Construction - GW1_20231214

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° ELLL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: ""��� pp 61..), I
L k 'tV E4---e C.4:WATER7ANES _ . ,. _1-:IT:-.I- z_ . .1,-71r •. --.- •-- .''::
Well Contractor Name FROM TO DESCRIPTION
- --- - tot" ft ;1 6P►t� ? It y d vt,Fvac i4 e �� i-1, t-t S,v'N, f `i� 9 :i ft ft
NC Well Contractor Certification Number D r C 1 / 2023 ;�1 � :
5:;OVIEER':CASING(for•'mtilti=case"dwells)OR-LIl�IER(if:ap licable)•-:�." '- =?{,�
Yadkin Well Company, Inc. - FROM TO DIAMETER THICKNESS
y* I ft. C ft 6,i t®S in. g D Q.�a 7 17
Company Name ll:t:,....:..':^'1:'''".: :-.^.-:3iJE, - --_- - -
w,D.:3 _16%INNER. G:OR.TQBING:(peother aleldsed=loap)` : _ -_ --:::-. •..
2.Well Constraction Permit#: a�s/ (�
"v '' J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIG County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 2 1:7;SCAEEI$. =
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑-M`unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) presidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :'18..GRoUTr - - - ---
❑Irrigation ❑Wells>100,000 GPD FROM TO MAT
ERIAL EMPI.AnnmENT IVIOETTIOD&AMOUNT
Non-Water Supply Well: 0 ft. soa ft. g@rt'rOrr,'f(03 f•7 y )ve_ , rre-e .
❑Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
119.SAND/GH2AVELPAC1C(rfipplicable):----------- -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _'
DAquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer ':20iDRIIIIINGLOG.(attachudditiaiizl'iheetaifiiiceskaiy) - __
FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) it ft. t
Date Well Started A// l e> i31l� ® fa 5 ,l l q. t.Cooe $if -e
4.Date Well(s)Completed: dtI/411)/�'3 Well ID# A.P b 9®.- g 1 ft g 9 ft. C,,,,,,'4-` G
Sa Well Location: Phone#:2 6l-, ` ,-1 O2" ft. ft. r
+viAt;1 Cors Vrinn'3 /02 ft i/®®3 ft `�vAg.t4, / c1, Glf�e e
Facility/Owner�/ Name j� Facility ID#(if applicable) ft ft
/0 I'S CG.)9?v' 114(A)kfrp p R vot.[ft'�i'i ft. ft
Physical Address,
pci ,,andZip t��bai • ft ft. - -
Y • A 1 1 •C J 0701715 ,.2I:RFMARHC�..- __ - :_L.- ©...•._.___. �] ._.- ---' - - ---_�`'
County Parcel Identification No.(PIN) 1 b o i-1 o�.C-5s D jl $� O �-g5o a sws®f g`
I.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '.r ' `�5 -S C.) ('$
(if well field,one lat/long is sufficient) i 22.Cer u r,ation:
' , .4„,,,...--(1)... _ (-)70e179-12141:12F„.„9
6.Is(are)the well(s): t7Permanent or ❑Temporary :gna.•e of Certified Well Contractor Date
:y signing this form,I hereby certfy that the well(s)was(were)constructed in accordance with {
7.Is this a repair to an existing well: ❑Yes or fitl<o ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy 4.
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 remands 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 inf., CCC777���
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 1 ecessary. C,
drilled: / 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 00 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q2/00'and 2@100')
10.Static water level below top of casing: Lf 00 ( ) Information
For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use ( Infoation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6cn.)Bit Off: 51 9 5o 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(RTC)
p� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '/I i(Y' (� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1'
(i.e.auger,rotary,cable,direct push,etc.) Pk,
county environmental health department of the county where installed
GM—
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 p '
13a.Yield(gpm) �7. Method of test: I � 4 e✓t°1 U.Le®ts 0
70% hth Date Site Visited:ft— 2-,2-.2,2-.2, ��- ad. i i ��,��
13b.Disinfection type: Amount: 93� Oz Site Visited By: 0 - (A 0 P
Form GW-1 North Carolina Department of a virorumental®uality-Division of Water Resources Revised 6-6-2018
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Price: ------ ------ - - _ _ -- - ---- - - -