GW1--00667_Well Construction - GW1_20240125

- I,11, CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:/►� !M g
Td WI I /( �.1 (/ 1e 14WATE$ZONES .: - �.. -_ _.-•,
Well Contractor Name FROM TO DESCRIPTION
�� 6 j e 5. ft. 1 6 6. ft. 1 f �1�
4O0ft �il S f' 1 . ' _t
NC Well Contractor Certification Number 15:OUTER CASING(foi•niilltirceset Ne➢sZORLINER(if:ap livable)°.'•. '
Yadkin Well Company, Inc. FROM TO DIAMETERcrassIm,TERTAT, dS
ft. It. n.
Company Name C..14(-e.sa= D 2C O//- ` s� :.16:IlINERCASIl`IG'OR�.TCIBING•(keoth`ei•mando"se'd=1a"o -.:.: ,•- •• -
`A -lMNsd,�-- on -tit S
2.Well Construction Permit#: S FROM TO DIAMETER THICKNESS _MATERIAL
List all applicable well construction permits(,e.UIC,Comity,State,Variance,etc.) I ft. 13
7'ft. C 1,6 in. .SZ)I.'-.21 G?t''c? a
3.Well Use(check well use): ft 1 J ft in. 1J46 f F
Water Supply Well, :171SCRF1E1`�.., ::.'r::::,1,':a=i --L'::k :: .,7.'-:."..r':,, ••7.1..:,1-2 .
FROM TO DIAMETER'.. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M,�umcipaUPubhc ft ft in.
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft �FL� in
❑IndushiallCommercial ❑Residential Water Supply(shared)
❑Irrigation _ _ ,- DW,ells�,100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply Well:• 1-. C•= 'v v y ft. �{{ ft. e o n ' l't i S / na (
.�,.. -0'0...-t V Z. �4(9 17t,+vA•�. Sldv,y ,rsagvtj7 �reke 1f,.try/ �
❑Monitoring 2 ❑Recovery ft. ft. c I.--t'r
Injection Well: JAN eft ZOZ4 '
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation rrr r. E! a. 1'19-SAND/GRAVEL PACIC(if appli'c'able)'.`.•1 ':_.: �.;.- -a:1.:-t.
❑Aquifer Storage an �p(gryC ll 1�..•••` J�allmty alI'ieI FROM TO MATERIAL EMP CEMENT METHOD \�
❑Aquifer Test Q1ry O'I. OStormwater Drainage ft ft. /
❑Experimental Technology ❑Subsidence Control ft. ,..,_.-fe. _ }�
rm❑Geotheal(Closed Loop) ❑Tracer 20:DRITLINGLOG(attach a dditional`sheetaif.iiec saryf--''::`,- 5 :;'y;:, IT)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type Brain size etc.) ,
' Date Well Started_ 2.- - A CI ft /.S® ft .-S© ) / ! ..SAC, _-
4.Date Well(s)Completed:f B`14-Z 3 Well ID# P- q t..s' !Lc, ft. ' ey 3 ft. 6?^r-
Phone#: 33C-X2- ‘Qc,7 /'
5a.Well Location: �� ft. f Q ft. 1`�rti
8i e,,,, I1t /tey -f^`+sYel,etr,
1 6Ift. Luft. •! ` C �c. '`AiPi t I��4Ug ce- r
Facility/Owner Name tf Facility ID#(if applicable) '7 i ft. 1 9 0 ft r e.G 1 v 5U'. -40. l �. a
'' e. 2-C! I ft. c100 ft. Si3.f I ?`zw.t 4 6
' Physical
gAddress,City,and Zip 9 0 1 ft 44(10 ft. 5,1 r p e (e 4 , S6_r 4- LS,
/ p.
i.. `J21RItIwARRc A.:::t :,r=`:.�:- . -__ ,,pY.;i.::�','•»'
' County Parcel Identification No.(PIN) Og?ve� ( ' a,c arnd .het Sect atYi ar,�`@ ha( V(1\_(xr-
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ''UC rt2 r"y
(if well field,one fat/longis sufficient I '
) 2Cerftflcation:
�,� l ag ature ertified Well Contractor Date ('k
6.Is(are)the well(sy C�lPermanent or, ❑Temporary ,
By signing this form,'hereby cernfy that the well(s)was(were)constructed in accordance wills 1/4/ '
7.Is this a repair to an existing well: DYes or L No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
' 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 remoras section or on the back of this form. 23.Site diagram or additional Well details:
8.For Geopr uhe/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: / 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: 1) '(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list al depths if different(example-3@200'and 2©100')
24a. For All Wells: Original form to Division of,Wa4ar Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
11.Borehole diameter: �, (in.)B It Off: 6 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Otf >/ • 46 44/y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auge,rotary,cable,direct push,etc.) county environmental health department of the county where installed -7
FOR WATER SUP'LY WELLS ONLY: 24d.For Water Wells producing.over 100,000 GPD Copy to DWR,CCPCUA !1$
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2i . G Method of test: S al t t 0
' - p°' Date Site Visited:/co•- m 2- 7 di
13b.Disinfection typ _ 70% hth OZ Site Visited By: 3 -
e. Amount: vV(1G
Ka • ,• 1-
a' )' Form GW_I
North Carolina Deg ment oEnvirotnu:ntal Quality-Division of Water Resources S Revised b•p.20I3
Price: , y�• tee a: �e�4e 1 {y �IJ