GW1--08009_Well Construction - GW1_20231214

• , .._:=JELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
a .e j Neit( t 5,14.'.WATER=ZONES ..:n ;t':i O1},itli:;vw•"_',e::." 2.. . 's?":J..,,San, .
Well Coahac/[orName FROM TO DESCRIPTION
8(4 I3a ft. l 3:�ft 1.1144 /-04n� I h t'!It,
ft. •• ft
NC Well Contractor Certification Number �.;. {+;
tISTOIITER'CASING(formnitV ased;we71i):OR•LINERi(ifap`u able)i
Yadkin Well Company, Inc. FROM TO DIAMnraJ THICIcNEss 1 MA
ft ft. in.
Company Name e a+
/p,� `.•)16zIlIlIl���NF���RRt�CASILIG:OIi:luB1NG;(eutliermaldoseLloop)7;tc""""`�"'" e;;;;:. :a
2.Well Construction Permit#: �✓ FROM TO DIAMETER • THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +.' ft e/6l('/ - ft in- /!9.r2s o g -l'�J'1,
3.Well Use(check well use): ft. ft b / in.
Water Supply Well: J:7r'Sc1 E '- - _...----.-.- . • ...._...._.._..
FROM TO DIAME SLOT THI MATERIAL,
['Agricultural DMunicipal/Public t in. J
['Geothermal(Heating/Cooling Supply) l esidential Water Supply(single) ft ft in. /
❑IndustriaUCommercial ❑Residential Water Supply(shared) D " OUTC - �:_" . • , • . _ 1
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply WeII: ft. ft yy / c� A5
❑Monitoring PP Y ORecovery ti� ft U � '�� G '� T �'.7 S•
Injection Well: /:. f. ( 7['Aquifer Recharge ❑Groundwater Remediation
i919;SAND%GRAVEL AC (if appIic "_aliI. _ 72 -
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO MA EMPLA_ METH _OD ' "
❑Aquifer Test ❑StormwaterDrainage ft • •
❑Experimental Technology ['Subsidence Control ft ft •
,
['Geothermal(Closed Loop) ❑Tracer 7..20aD - GI:OG'(s`ttarlradditional sheeti ifnecessary)s _,,,__ ' : . .. r
•
❑Geothermal satin Cooling Return . El FROM TO • DESCRIPTION(cola,hardness,solllrock type,grain size,etc)
• (H g/ ) (explain Remarks) S ®t
Date Well Started I ®e"J �3 / 0 ft. ft
4.Date.Well(s)Completed: :li/,0-/aI' >7WelID# L1 re- 49.,: (" 'ft ft / /__-
!� 7 cif", -- hoe
5a WellLacation: Phone#: AID ft. 11? ft {ll l ip bil. .S.ay,-
• A c.I¢.,,,k . nn i- /SuiQ4ars:. I-.3 R 136 fL ).c.h,)— p 7 G.-f,+-, (�.t
Facility%Owner Name Facility ID#(if applicable) ( 34- f(/2 d iv cf!y' a
AtvAu14 L;Ely LAa. sl ) r I�
Physical Address,Mty,and Zip ft ft.
V V O.A,. Q! 2 .3 • Wip,--76,g-\ F.i212RF.MARKS P�,,,.-.` ... c....,:=:_.._.:; .•r�.-_.'_..==7f. .
County Parcel IdentificationNo.(PIN) •
v r'"� v••-•a..
•,s �s ,
...an"
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G f•r i / �Ny
(if well field,one lat/long is sufficient) 22.Certification:
l• - I JJL 3
36a iS S1-i N SL9tr363-Z W �"'••• ln;�rr _ ^n:''' ^ ;'�r
6.Is(are)the well(s): 1�t'ermanent. or ❑Temporary ✓�;d(�'D to���`'
Signature of Certifie Well tractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or To 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,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 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 I GT 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 69 0 (ft.)
For multiple wells list all depths ifd jerent(example-3Q200'and 2Q100')•
Submit this GW-1 within 30 days of well completion per the following:
? 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: - _o (ft)
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: lP (m•)[3it Off: 4). d 30 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) •
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a ,P /'A Tea 17 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: t 24d.For Water Wells producing of er 100,000 GPD:Copy to DWR,CCPCUA
i� Method of test C/6. et / Permit Program,1611 MSC,Raleigh'NC 27699-1611
13a.Yield(gpm) �/1
70% hth Date Site Visited: L
13b.Disinfection type: Amount: S OZ Site Visited By: ' 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: