GW1--00763_Well Construction - GW1_20240131

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TJ.,.�CONSTRUCTION RECORD (GW=11 For Internal Use Only: -
��1.Well Contractor In^fo�rmation:: .
t) 0 Q ',/ V f / ( V "La 11;i 'd"jr CU.WA 'ZONES":.'. :ffi F_•_;%r.4":,-t t_':'_ x+:- - -
FN FROM TO DESCRIPTION "
WellfCyo9nhactor[/a(me ft I I.� ft lII��
6>V ... C (, - 4.(1.::is �,,i )-....:.... ® ll�
q 23sft .;�4z-ft. 7 liop,
NC Well Contractor Certification Number ��4� .
Yadkin Well Company, Inc. JAN 3 1 15.OU1'ER'CASING(focmulti eas wefs.ORLINER,(ifip li abu)";. -:,2,
FROM'" TO DIAMETER' THICKNESS MATERIAL
•sti;;,, 4°I ft il. 5 /ft
Company Name :' •-.:•^ -2 i,c•`: 99
'��y//'• / CA• (;•• '._:; .•I,,`••16:IIdNER CASING:ORUIIBING
2.Well Construction Permit#: /0 3C W FROM TO DIAMETER' "THICIINFSS MATERIAL -1
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft in. --„, ,
3.Well Use(check well use): ft ft in.
Water Supply Well: J.7 SCRF?El;:^%_=ic__' :�`.w= _,_*::� :;--- :i.:.:,_.,.--.- -_, ,,v '
FROM TO ft. DIAMETER SLOT SIZE THICKNESS MATERIAL 7
❑Agricultural ❑Municipa]/Public ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Indush7al/Commercial ❑Residential Water Supply(shared) - ---
. 18:.GROUT_-.._:..�-7r�_....__-._-,...:. ..,_ - -- -----'._---
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT �e
Non-Water Supply Well: 0 ft' . 3 ft. `)^ e tIiML� cL P< rater
OMonitoring ❑Recovery ft ft.
Injection Well:
ft. ft. '
DAquifer Recharge .❑Groundwater Remediation ---
ii19:iSAND/GRAVEIiPAC&-(if'ippli`cable) - -`:. "-=:_::->::--7a•7--E-=,. ..�.
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer i,,20:DRIf .AVG'I:OG`(attach'ndditionaleheetiif.iiecessury):J 7=7= "�%," -,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hareems,soi0raek type gra n size eie.)
Date Well Started ii'1_- i' -1-1 0 ft 6 1 S ft. S O V ' A(1 -
4.Date Well(s)Completed:i 2- 'j tl'L.) Well ID# AA' 'ir?ST 8 4&ft. 1 3 s ft tti/•[s4.,.. eV dcl ki.., a t ck
Phone#:7 -07 9 S') �‘ ft. p ® rt. -�
5aa.�/Well Location: (> �, R t/t �Gti^ t� s;Z
Y'I t e,0 i C f'A I s- I ( ,' ft. 1 6 7 ft. B ro,n/� n-CDC,
Facility/Owner Name
' # ry F)acility ID#7L(if applicable) f k ft. y e 5 ftF•q-04 • t P ec'
,209 1-mkt i?td:9 l,0V, 1%) he.) &2,,,, 16(3 ft. ul�4A 5 ft. J 3� `C Ij tl•a,�.
Physical Address,City,and Zip J �j cf /(�1'^� e.i 1'ft. �t C n ft �"►V..��`'4. LO C f%¢.4 r i+f,,�m
kes l! \ I D21 RRMABILS:r I-7,-1"1. ., ,......:1:.::.... - --,._..4-_.�-7:.//:,,,,..--_2r;'
�n t.
County Parcel Identification No,(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onee lat/long is sufficient) ry 72Z. ti£Cation: o •
3
6.Is(are)the well(s): [ rmanent or DTemporary 5 d Si:
Pe ..,:tore• •• rtified Well Contractor Date
/`����� By signin•"his 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 @Irlo Cp....v 14 1SAN fC 02C.0100 or ISA 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 ofth'•'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 - ‘.. I
// 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 Cs 0 (ft.)
For multiple wells list all depths rfd(fferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
'a, •'\. i 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: E C, - i d. (ft) Raleigh,NC 27699-1617
If water level is above casing,use"+" Information Processing Unit,417 MSC,Ralei tJ
• 11.Borehole diameter: L "in,"Bit Off. 24b.For Injection Wells: Copy to DWR;Underground Injection Control gm)
Program,1636 MSC,Raleigh,NC 27699-1636 -
12.Well construction method: CN,e r • lil a 4-env'i
(i.e:auger,rotary,cable,direhtpush,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
t county environmental health department of the county where installed • t -;
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:copyo DWR,
}� � CCPCUA� eel
13a.Yield(gpm) - tl 11- ; Permit Program,1611 MSC,Raleigh,NC 27699-1611 ® all)Pie.", ....,...• I
•Method of test:
70% hth �)• oz Date Site visited:A......7,Sd-2 7 /a 4'i2. V 1, , � •'ti
. 13b.Disinfection type: Amount: Site Visited By: r,i
a, - is
Form GW-1. North Carolina Department of Environmental Quality-Division of Watel Retool-,es R.,,.i R Ised 6-6-2018 `i
Price: Ir` kac.�s