GW1--00771_Well Construction - GW1_20240131

,WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
=L'Welh'Contractor Information:
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FROM _ TO DESCRIPTION
Well ContractorName 5 7 ft. 5• ft g , tt
NC Well Contractor Certification Number ;i15;017TERtCAMG'(nor:iniilti=cased;weIIs):ORISNERTid?ap llen11e)1-:__21-I'',;:_
Yadkin Well Company, Inc. FROM To DIAMETER THICKNESS MATERIAL
ft ft " I in. t
Company Name $16FINNEXCASRNG:ORaTMING(ge itlfermalchissenifip) =--� " -:LY'.
2.Well Construction Permit#: 36 , lti' Q FROM .TO DIAMETER THICKNESS _MATF.RTAT
List all applicable well construction permits(i.e.UK',County,State, ariance,eta) + ft. 3 1 ft C. 9 s' in ,5. � 21 r
3.Well Use(check well use): 1 ft ft in.
a .7at Z.:::..
Water Supply Well: FROM TO DIAMET SLOT SIZE l J THICKNESS MAT
❑Agricultural ❑Municipal/Public ft ft. in.
' OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ' ft l in.
/ .. 5"
❑lndustrial/Commercral ❑Residential Water Supply(shared) •'.::SBi;GIFOuw,... _ . ''_' `��—"-z_= -7'-`— _ -- - -�
❑litigation ❑Wells>100,000 GPD FROM TO MATERIAL EIv1PLAC1+3vffilikeTlaon&AMouNT
Non-Water Supply Well: 0 ft 9 I •ft -a �11 t'% 6 'i / 1 °4rJ� 11740
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
1.19;:5' 1GRAVEi PACK'(ifnpplica0e).�'= =2:72.7.C.17., ..=...11..�:
❑Aquifer Storage and Recovery ❑Sal inky Barrier FROM TO MATERIAL ENIPLACEnffi7T TROD
❑Aquifer Test ❑Stonnwater Drainage ft r ft.
❑Experimental Technology ❑Subsidence Control ftt l it •�
0 Geothermal(Closed Loop) - DTracer _20 DRY)ZNGI:OG'(attarh•s.adition" rslie"eta$,iii-d inky—);'w._ _--�_,
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO =DESCRIPTION(color,hardness,son/rock type grain size,etc)
,r_2� art ft; ,. �' ,I Date Well Started �j ©,,
4.Date Well(s)Completed:1 2-d 5- a) Well . ,' P--'� /e ‘ I . ft I �. ft ¢'��1 k�2_ , q
Phone#:
Sa Well Location: 3'( zft. t p 6 h.
A V f d` e9" ri`d- 1,,,,,,,..,
./4 l ke, Lock 4,+ coAS4•--- 19 Oft I I-5 ft. P;m vdc.ie_
Facility/Owner Name Facility ID#(if applicable) !r.S ft 5 01 ft 145(i/lle C
.
.SrokkA �rrO& O'o1Q at�7 ft ft. c/ '
•
Physical Address,City,and Zip ft. ft rT.,, •Y_
e4 4 A 4$C;tyN :r7.ZREMART{.S`'--:.E`:..—.�`:=T. '.r -..1.7_ i.:1
17-_, .-- ___::» --
County a� ParcelldentificationNo.(PIN) _ �""
JA N 3 .1 202 .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4
(if well field,one1 lat/long is sufficient) ilia .
p �p �j 22.Certification: ' - •
R�A �NIc aN�A ���A W lfl:r�r:=` `E�`:', '-_. ' r,ii
w j._ Z.
6.Is(are)the well(s): i 'ermanent or OTemporary Signature�fCeiti�ied Well ontmc ate
By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or to 154 NCAC 02C.0100 or 1SA 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 constniction info
construction,only I 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: r (f.) Submit this GW 1 within 30 days of well completion per the folio-Wag:.
For multiple wells list all depths tfdifferent(example-3@200'and 2@100) ,
10.Static water level below top of casing: 1.0 4 (ft.) 24a. For All•:Wells: Original form to Division of Water.Resources (DWR),
If water level is above casing,use"+" •Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617.
11.Borehole diameter: (in.)Bjt Off:4 05. et 24b.For Injection Wells: Copy to DWR,Underground Injection Control•(IUC)
p ° Program,1636 MSC,Raleigh,NC 27699-1636 ' ,
12.Well construction method: fia. d '�.P�y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the V.
(i.e.auger,rotary,cable,direct push,etc.) C 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
(� ° Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) D Method of test: rr� ej/ I
70% hth Date Site Visited: /�
. 13b.Disinfection type: Amount: OZ Site Visited By: PA tom' U't U
•
Fenn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: (04t'.r,f 4' S - t.)