GW1--01609_Well Construction - GW1_20240313

, ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • '�' `" '� --c e? 1,., : , .
1.Well Contrac rInfor lion: MAR 1 ,. 2024
`t ' ! —'Ir� 74 NWATER:ZONESL s::::iz:-o_,ttaei!;':':':i:•.:'jn�_ .'Y.�e." �i� -- .=t:.`.'i,:3::y
Well Contractor Name FROM TO .•' _DESCRIPTION ~''""-'°``,:i'-...1;
I�1� IS ft. j .7 7 it S it- ,a61'n 1 i 114T r .
1 112- ft. ft. ;
NC Well Contractor Certification Number +,
�i1S.•:OD'1TitGe1SING'(ioc�miiltl=casedweIIs):OR' lFRCIf;•ap licalile)= ....__:^
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL)
ft ' ft
CompanyName r_^Y r,
}� i:161IIdNIICCASING.OR- ING(geotltei'miil:dosed=loo'p)c*+�=-"�' �-+L=.,_
2.Well Construction Permit#: /ate 7 lit/ FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.UIC,Coarty,State,Variance,etc.) 1.) ft. `7 f ft. , `4, �' '3 jD P.. h 1 P�L s c
3.Well Use(check well use): ft. 1 ft + in. J/ w r
Water Supply Well: a7:SCREF =� -� Y --: =`- _ "_.:='___' ..
FROM TO DIAMETER - SLOT SIZE`. THICKNESS MATERIAL
❑Agricultural ❑�M�unicipa]/Public ft ft in.
OGeothermal(Heating/Cooling Supply) ffil sidential Water Supply(single) ft ft in.. '
❑Industrial/Commercial OResidential Water Supply(shared) '-ls.Lagty T,�,_.,:_ =_--- ---'-__--__.--_�_ __.,..__-__.�__.,-_
I:Irrigation ❑Wells>100,000 GPD FROM TO �• MATERIAL~ EMPLA ENTMETEOD&AMOUNT
Non-Water Supply Well: 0 ft • 3, - e Yl i C3,5 �'1�`tI J - ' ,5 J ILCJ3 . .
❑Mdnitoring ORecovery ft. ft. ,\re' n (ArylP (
•
Injection Well:
ft ft
DAquifer Recharge •❑Groundwater Remediation _ _ '
1519:,SAND/Q2'AYEL A.CKGf:applicable)::_—_--:- =.=__._.j.,...:1-.'_:.`_; . .
DAquifer Storage and Recovery OSalinity Barrier • FROM TO MATERIAL EMPLACEMYIENTMETHOD '
❑Aquifer Test -❑Stormwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. . ft ,
❑Geothermal(ClosedLoop) . ❑Tracer '2diDRIGfffiGTUG"(attachfddihioual'slieets";ifneceiary"')=7._ =
.�•':' . �, FROM TO DESCRIPTION(color,hardness,soWUnirk type,grain size,eta)' '.
❑Geo•theiinal(Heating/Cooling Return) DOther(explain under#21 Remarks) -
Date Well'Staited - p� a� 0 ft I� ft. ic.O& G�y 5®�1 ' •
4.Date Weil(s)Completed: ! -I k'- V Well m# P-- 97 in9'i :�:... A)...,ft. S ri
Phone##: S1 7- l50-. ,0 -f-a;.`�'11 ft.. ex Z►
5a.We,llLocation: �(� �
A , e1i6 Ayot(4 d ft �l�. ft arc l-h
Facility/Owner Name Facility ID#(if applicable) ft ft is _ .
7 LC . . l q f r/ 1 .�.� f.
A . k . , ft,. ; . ,
it ft
Physical Address,City,and Zip .
p.e I. [:,21,R'RMA12Kfi:`,v _...-. - _ __ _-'_-
County Parcel Identification No.(PEN) -,-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ,
., (:) '‘l€14 N &/, 2J3�0 w -�2 yg .•
6.Is(are)the well(s): ermanent or OTemporary _ tgnatute'o Certified Well Contractor•
- Date
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: DYes or IV Va ' 15ANCAC 02C.0100 or ISANCAC 020.0200 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.
it
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 J
construction,only I
GW 1 is needed. Indicate TOTALNUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necesSary.
. drilled: • I 24.SUBMITTAL INSTRUCTIONS e�
9.Total well depth below land surface: ry�l`�2`' +' •; "---
For multiple wells list all depths i d; Brent*ample-3 00'and Z !00 (f t) Submitthis GW-1 within 30 days 6s igel completion per the following:
eP B ( P +
`f tz • 24a.Fd AII4.Wells: Original folim to Division,of Water Resources (DWR),
t : 10.Static water levelI el w top,of casing: `1 '.� • v (ftl' Infors:�±tion 1~rocessing Unit,1617 MSC,Raleigh,NC 27699-1617' '
n 'fwater level is above ast use :� -;;1; a ' _§ 1• ,. f.:'% a '
r ?Ab:For Injection Wells: Copy to DWR,Underground Injection Control(1UC)
11.Borehole diameter: ._�._ (in.)131t off-....:. C7 program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction IniOnu.*:` / jY TCi )" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i:c:augr;n,tary;'cable,direct push,etc.) county environmental health department of the county where installed
• t:
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, MSC, g „NC 27699-1611 I
13a.Yield(gpm) r�� Method of test: ��9 I 1611 Raleigh
,,NC ��]led. L e ID(s. 1 0
h OZ
70° th q Date'Site Visited:7- 21,
. 13b.Disinfection type: Amount: • _- Site Visited By: 0 I 4D��`i'
Form GW-1 �_.North Carolina DpPlartment of Environmental Quality-Division of Water Resources Revised 6 b-2018