GW1--00559_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
#13 4 WATEIt•ZONESFLems . ,:':-.t1Y.sC:'... _�k';:M -1 ,wz?t?>i.=:».J.:. ."}).
FROM. TO .• - DESCRIPTION
Well Conhactor Nam 20Vt. IL
_ J44,' / ra x
7 � • ft. ft I �° „c
NC Well Contractor Certification Number 115r DOTERCASIING'(formniti='ce'sedvvellsj.ORLINER(ifs`licable)T^^;;,x5.-°;'_=?','�,
Yadkin Well Company, Inc. FROM - TO DIAMETER' THICKNESS i MATERIAL
ft. ft i in. •
Company Name 116:INNER'CASING.ORTQBING eotliermalclosed=ldo" Xq = ;m.
2.Well Construction Permit#: // V 4 FROM TO DIAMETER _THICKNESS MATERIAL 1...-
List all applicable well construction permits(I.e.VIC,Cowzy,State,Variance,etc) 11 ft. 57111 ft d vi, + in. 493 (,l t vc,
3.Well Use(check well use): ft. it in
Water Supply Well: -J:7 SCItLEIAr✓ :r;: ?L: :-1. . .•� ^"t :_: '�"n
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Alkesidential Water Supply(single) ft ft in.
❑IndustriallCommercial ❑Residential Water Supply(shared) i-18.KGROII1""•'G`y' 1‘"1' > - ="----'---- -
❑Irrigation ❑Wells>100,000 GPD FROM J TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft �,j 6 it ���� 'sip
J ��n,,v�4
OMonitoring ❑Recovery ft. �j ft. AO Virri 9
Injection Well: ft. ft m
❑Aquifer Recharge .❑Groundwater Remediation �" �, _
1119.SAND/GRAVEIIPACW(Ifnp cable); ?. -•""- .11 •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD •
DAquifer Test ❑Stormwater Drainage ft ft
DExperimental Technology ❑Subsidence Control ft. ft. .
O Geothermal(Closed Loop) ❑'racer (:.20:DRIX:I IGI:OG"(attachadaittoaalsheeta`id.necessary)." r, 7.7,%u
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solllrock type grain stze etc)
Date Well Started �'„�/�= �Q�Q 44
4.Date Well(s)Completed: /�/3• Well ID# iJ/� 'v1� ft. Wit. ,�tat/
Of ft ,?yxit ,env� i 9 J 4 ef ef-r '1.4
Sa Well Location: Phone#: a,'me?-fl7 0�., e ft. ft
.��// p ft. ft. •-:1"i-v n T_^m rr�.-,
141�j' ir'tyI 'ref e..l e P ft ft. i 'A' (-'t"�J fi'1 �'`
Facility/Owner Nellie Facility ID#(if applicable)
ein,ar ft. ft JAN 2 5 .ZU24
Physical Address City,and Zip Pj t SLa g sS ft ft. , ,,i It <:1 Prr r,! e L,
•
County Parcel Identification No.(PIN) I. ~'•
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • •
(if well field,one lat/long is sufficient) 22.Certification:
014 1 e n N $2 . 79 0,.J'7 0 w J - .
ix.43-- gi.23
6.Is(are)the well(s): ermanent or ❑Temporary Sii. aofC ell Contractor Date C%
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: DYes or Igqo 154 NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information c68 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 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also,'attach additional pages if necessary.
drilled: G s 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: CO (ft) 1 -
For multiple wells list all depths ifd8erent(example-3Qa 200'and 2Q100) Submit this GW 1 within 30 days of well completion per the following:
of casing: 6S 0 s ' ft 24a. For AU Wells: Original foam to Division of Water,Resources (DWR),
10.Static water level below to
If water level is above casing,use"P' g• / ( ) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617,
11.Borehole diameter: ep (in,)git Off: 4 o O7w 24b.For Injection Wells:Copy tf DWR,Underground Injection-Control(IUC) �1 Program,1636 MSC,Raleigh,NC 27699-1636 `.:-
12.Well construction method: P-0 Q I tI•.,•�.
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water SnppIy and Open-Loop Geothermal Return wells:Copy to the
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
L
13a.Yield(gpm) Method of test: ®�' Permit Program,1611 MSC,Raleigh,NC 27699-1611
L
70% hth Date Site Visited: /1 s V-.2_1 or.
13b.Disinfection type: Amount: t A A a OZ Site Visited By: �0� ! s.
1
Form GW-1 1 ` 'ental Quality-Division of Water Resources , .Revised 6-6-2018 43
. Price. 1 -