GW1--00767_Well Construction - GW1_20240131

' _WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: I
",��t�A !/ i/e. EraimAT `ZONES', ?,.;.-;:".:r;-1,Ta=.". _ . 1;1.-e!'::21 _:_ .::..:.. • , .
Well Coot-actor Name FROM TO DESCRIPTION
, s 4 e3- /4 yc7?it 0 ft t2rd LlA Rot,*
ft. ft
NC Well Contractor Certification Number 115:OtTER'CASING'(fo`r`mulfifcased'fvelI).ORI M:C(1 a-1icaTilefx:.7."-_ ,' .
Yadkin Well Company;Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL -
ft. ft. in.
Company Name }>�,,�,-..may.
c161INNER'CASINGOR:TUBING:(ge`otheriiialcio`sed=loo ,11= � .w'..._'•:;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ÷ ft, 16 6( it
050 in. II ? q �I-ttv1 5.e e-
3.Well Use(check well use): ft. ` ft. in.
4
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft.
0 Geothermal(Heating/Cooling Supply) W.esidential Water Supply(single) ft f .,�1n
❑IndustriallCommercial ❑Residential Water Supply(shared)
❑Irrigation ' ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - { Li 0 ft. 2 5. ft 6-91i4y,l'/-t („I io 1 pd(.4 I ie A
❑Monitoring '-r,: e1 l❑Recovery ft. ft ).a- 6G Uj s
Injection Well: (('11 ft ft. s/
❑Aquifer Recharge 3 p•,•, u �u.0Groundwater Remediation•
_
„ 1:19 SAND/GRAVEIi•PACK'(ifnpplicable)t__ = .-"_�__ -�-..,.i".»_._
❑Aquifer Storage and Recovery J _r,.,7. ,alin tt Barrier - FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ;n; n::': ;Y 64'_(.1,G❑StormwaterDrainage ° �ft7--- -"- ,�
•
❑Experimental Technology ❑Subsidence Control ft
OGeothermal(Closed Loop) ❑Tracer , /] :2ti DRYLLfBVG1.53' (atiscli'additions]'sheets'id.aecra�ary)` ��__72 2 7=
❑Geothermal(Heating/ ololi Re 0 Other(explain under#21 Remarks)
FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size etc.)
Date Well Started 1�` !� 0 ft. �. ft. �'O 1 d _
1 �� i
4.Date Well(s)Completed:IA 3 t--co) Well 1D#A --r,'?:-.0) ft 6 ft 9 i ?
5a.Well Location: Phone#:13uta-I K-1®6 g 4 9 G ft CO ft F.ra l (,j. j- -
a "AI yl/ CO q ft' /, 3 ft ! fo G 1'CA r't Ili L�
Facility/Owner Name Facility ID#(if applicable) 6 J ft. '� ft Se° 1 ill 9r�-7 a, tn.d►l�z - 17rae..,-
1 -7.) ® "Alit rio A Carr Q..# Rd b00Aq, I70 ft. 130 ft. cn-e giu' c,s'6..nr lic
Physical Address,City,and Zip a t f o U f 3Q ft. r/7 ft fo Ff I( t2 4./t✓., - e't I�t, {FA,e- .
A 4twc l� i.2S;REMARKstv...-: v .ti �_ 14 r _ y.--.
County Parcel Identification No.(PIN) o
T` ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Certification:
w VAIT74 e-&kA1-9' t):-ai 3
6.Is(are)the well(s): A.f.'ermanent or OTemporary
Signature of Certified Well Contractor Date
By signing this form,Ihereby cerh;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Vo 1SANCAC 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 of this record has been provided to the well owner.
repair under#21 remarls 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth bow land surface: 5-1-0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4200'and 2@100)
q. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: r (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If waier level is above casing,use"t"
11.Borehole diameter: 6 ((n,)Bit Off: ! /I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A e P r.?4 A.f' 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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
e Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method oftest: ;l` 2s are r
o to Date Site Visited:,�"/1 Z I W c/2 t A 6. 13b.Disinfection type: 70'o hth Amount: OZ Site Visited By: - I
Tr% A are o -
•Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018
Price: c. con e'er