GW1--00772_Well Construction - GW1_20240131

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WE '''i'ONSTRUCTION RECORD G( W-1) • For Internal Use Only:
1
1 Well t''
actor Inforym/�,a/tiioonn: l
_ 9��R" J (ill'''' '.7-- F.Y:,WATEB..IZO W.].tal-'v i--,.�.'.•.•_3:: r.y::1^.`.e�Y i-�?'� 4i-.-_..:......:J.i4 ..-d C7i
J FROM TO DESCRIPTION
Well Contraeto�rryNamee ft.' ft
11610 /i ft. ft '6OO Sr% •�
NC Well Contractor CettiticatienNumber x15101TTER'Cif.SING'(fors:mylli=cased'wells)'ARLINEIC(if, -licalir4 •:,.v ^_
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
• ft ft. • ha. '(''
Company Name '316$INNEk,GASING OR'.TIIBING(geoi do l d tI1 oted:ldop) =f, ,'L E
2.Well Construction Permit#: I I S I I FROM ft. ft TO DIAMETER THICKNESS MATERIAL -
i i
List all applicable well construction permits(i.e.lI1C,County,State,Variance,etc) A
3'.Well Use(check well use): ft ft. in. - ��
Water Supply Well: r 7 SQEZEF.,r2... _"= _�` '_-- '��- ------
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agioultural OMunicipal/Public ft ft. in. —t
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in. 'ele
' ❑lndustrial/Commercial ❑Residential Water Supply(shared) ,:iei_G1tOUT :.. _ ___-_ _ _,- --_-._ --
❑Inigation :Melts>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyWell: ft it f r,{
1 ►, _•i',,i.di'iN"V :a
❑Monitoring DRecovery ft. Q ft.
Injection Well:
. ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation
1-191:SAND/GRAVEDPA'C Ctifspplicable)'f - :::::::7_--.-: - - - -_._Y- . .
_ • ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM . TO MATERIAL EMPLACEMENT METHOD •
❑Aquifer Test ❑Stor mwaterDrainage ft, ft
❑Experimental Technology ❑Subsidence Control ' ft. ft •
0 Geothermal(Closed Loop) ❑Tracer t 212At Il4CYI:OG'••(atf eh additional"sh'ectiifn'eerisaryy),: ;:: --` _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) -FROM TO DESCRIPTION color,hardness,soil/roelc type grain size,eta)
Date Well Started i 1-- .q—7 7 ] 6' ft. ft.
4.Date Well(s)Completed: l A,- (1/-13 Well ID#AA P4- 4 l 5 . Ito.c-( ft ,t v 1
5a Well Location: Phone#:S i— 6p� m&�/ Ri- 1 t. 3/16 ft. w ° ,)
• -3JR i1 R.� 9_,rC 0 r/ rr9 '' ft roe ft �./_ p L^ ht� L
•.Facility/Owner Name Facility ID#(if applicable) ft • • ft C�� +'/ter!
ft ft f.
3S I Ufa Q A Affo i.,r Pi lM v9g(0`� '? T, • ... .,'
Physical Address,City,and Zip ft ft. r=-r: V I..... l
DNA
County Parcel Identification No.(PIN) . • . •
-Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -. L•�,. ,,,6
(if w Ly/ell field,one lat/long is sufficient) 22.Certification:
A 6 - N b 6 1 5-48 t9 w /er✓l 1 t,-" y
6.Is(are)the well(s): ermanent or ❑Temporary Signature ofC ed Well Contractor Date
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hfi,,+t� D 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: rsl es or o . ISANCAC 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 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 GyW-1 is needed. Indicate TOTAL NUMBER of well's (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• drilled: l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! W (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(g100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: aLS (ft') Information Processing Unit,1617,1VISC,Raleigh,NC 27699-1617 •
If water level is above casing,use"+"
11.Borehole diameter: • (m.)Bit Off: 5.9 l I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: Gl ijt to-hi Py •
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA \--1
13a.Yield(gpm) /2., • n
1Ylethod of test: 11A' p,6` ��
Oz Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: UV
13b.Disinfection type: Amount:
L Site Visited By:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources •: •Revised 6-6-2018 ...
Price: ,(
Price: S.4 , etd,sa AreA °f •