GW1--08041_Well Construction - GW1_20231214

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WELL CONSTRUCTION RECORD(GW-].) For Internal Use Only:
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1.Well Contractor Int* lion:
CV'DLpj'GI ��� A)r i„i44W.A.TEIt°ZOIIdEES�''S ? tAJi:- �^•^c:ri. :e;T",c:.:>7.-.
/ FROM .t.:r.:,TO DESCRIPTION-.r
Well Cont®rNam� ,
3 � ��.35�`, .�E�b ft 3 ra 61��"`
• :- ft ft
NC Well Contractor Certification Number
15YOU' :CAErNG'(foi»':multi=casediiiellsTORIDIEW(ifiip'lleVi7a) ,.,_w.:%;.i.o..
Yadkin Well Company, Inc. FROM To () DIAMETER THICKNESS
• 7)7_
Comp any Name p_ 'I 33e_ -20 3- 3l��¢ i tz 5 d` it / 1�(, Ia ��ll'��
F •-e.e y N /� p�e)� •11aINKER;CASINGORJ.:111.13M aitlier'marclaiinio r;C-L�_ ;-11,:.:'l
2.Well COIlstruction Permit#: OP-3. J FROM TO _DIAMETER TRICEXESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,eta) ft ft in.
•
3.Well Use(check well use): ft ft in. _
Water Supply 6a 5.M1 . ,7,;.-�'-
PP Y well:
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) tit//sidential Water Supply(single) ft ft in.
❑lndustriallCommercial -❑Residential Water Supply(shared) +1a8,,, tyurc. ter- - -
j;
❑lrrigation ❑Wells>100,000 GPD FROM TO MATERIAL ` --EMP -CEMENT TROD&AM ISUNT
'Non-Water Supply Well: b ft0-if ft If.eyf/on t7r-(�tip5 H-y diw r tt^ f'kee•
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge .❑Groundwater Remediation Y •
119 SAND/GR 1'VR�L PACK(iifuyplicale); '-114Y?:e's; • ..
❑Aquifer Storage and Recovery ❑Salinity Battier FROM TO MATERIAL EMPLACEMENTMETROD '
❑Aquifer Test ❑StormwaterDrainage ft ft.
- ❑Experimenfal Technology ❑Subsidence Control ft ft. •.
• ❑Geothermal(Closed Loop) ❑'racer 026 DICIEMG'T:OG:(a fielra"ij'ditlii alslieetrilii ceisaiy) '- _.-__ .1'f.:.i
FROM TO - -DESCRIPTION(coloi,hardness;soil/rock type,grain size,etc.)
17Geothermal(Heating/Coo gRetun)) ❑Other(explain under#21 Remarks) / r
Date Well Started 9,$'/1/a / - 0 3 a s®r 1 `f Lepje ft-byte S
4.Date Well(s)Completed:Q l Ot7 ?j Well ID#!�}�ttP^ t.7 ?) , ft �' ft 1�r} b ./`�I ,C�ve.y//ice n
Phone#:3aK.C cii =OR 2 to ft. S 0, ft. [9 ► . ;S� 4c°-�
5a.Well Location: w"r �'f
•al" Gra •
/ ft 3) ft. -fr y g��('-- ' - l! Ca-°
Facility/OwnerName / Facil/Iitty/yID#(if applicable) • +j � ft. `," ' . r-, •--�
J 3 C1lo�� '1 h t kev4....S✓, • ft ft ?..'M• •
; V J
PliysicalMdress,City,andZip ft it nu 1• 1 . 2071
�y . log'7l�?9-455521.`RRNYAR7CR:.~. . 1.� ,_ �s._.._. .._�.._ -. r.
... fl,nit ;i i1 :)!7.. ,
County - FarcelIdentifrstionNo.(PIN) I � '14
°' 1 LtP;�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one lat/longissufficient) 22.Certificatio .
ZC , j B't 7Y. a N RC/, 10 at 6 a - ��Lac_-- 2 ___ ,
6.Is(are)the well(s): lermanent or ❑Temporary Si CertifiedWell.Contractor D
B igungihisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1,1. 0 1SANCAC 02C.0100 or ISd NCAC 02C.0200 Well Construction Stmidards and that a copy
If this is a repair,fill out(mown 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: • C
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 OW-lais 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: (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2(41100)
'V ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: uu Q Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+' .,.,
11.Borehole diameter: (in.)Bit Off: 6'D O 3 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,,((�� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f"r �, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departinent of the county where installed
SL
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA 1
13a.Yield(gpm) /0.
1
Method of test: °v Permit Program,1611 MSC,Raleigh,NC 27699-1611
0 2-•�
, 13b.Disinfection type:_ y
o Date Site Visited: 9-e-2..3
70/o hth Amount: i OZ Site Visited By: p,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018