GW1--01610_Well Construction - GW1_20240313

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, WELL CONSTRUCTION RECORD_(GW4) For Internal Use Only: ' • .••••._. ,,,,,,g„,,,t y L.L
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I:Well Contractor Information: ,.
ell rkuck\ -.._V .
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„ . __ __ ___ {7,14:19ATZOZONES).. .‘,....:__. _-_ _ ,.n.f.-•-•-•„..,." 7 ......_.. . • •.
., FROM •TO .,.'. DESCRIPTION. .-,s"•;..-:.--.`:„."'.'''
Well Contractor ame „
' 74, ft. "Ilf ft; . I/24. Gt.744.4f0 00.1 K:ocd kO. ,
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• NC Well Contractor Certification Number as!..01TTIRTCASINOT(frniiiilte-ilialfilia111).01CIMEBOX lieelirelL:: :=--
Yadkin Well Company, Inc. .• FROM TO .:, _... DIAMETER, THICKNESS! _ ',,MATERIAL- _
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Company Name- -
2.Well Construclion.Permit#: 0 6 kV. 4NNERICASENG:ORTURINGXiiiitifellial
FROM. .'TO, • _ DIAMETER DEC/CRESS' 'MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) .4* I ft. 69 " 4,/),417b= spelt _- fk. • ..
3.Well Use(check well use): . '. ft. ; ft. in.
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Water Supp ;
ly Well: ‘, rJ:i....7-..,:i-z.1-...t-1-!•-:.71:-..-1-:-.-._:."_':" •11'2.7.-_-2.-.1.-,...t-T-7'7,-7--
• ' FROM ,TO .- DIAMETER SLOT SIZE .THICKNESS •MATERIAL
DAgicUltural OMunicipal/Pixblie. ft.. ; ft in.
. • OGeothemial(Heating/Cooling Supply) At esidential Water Supply(tingle) 7
Olndustrial/Commercial OResidential Water Supply(shared)' :/azakixrarz-•-7,77-:.-7,:-!,.-.7-1;....a..7----T-..-• -
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DIrrigation OWells •100,000:CIPD• - FROM W. •MATERIAL EIVELACEMENT.IHEIROD&AMOUNT
Non-Water Supply Well: ' 0 ft. q#, ft 1),,,,eti
OMonitoring i 1
Injection Well: . ORecdvey. . -i'l ft' ?-311t; atin-Shorry. .„,,frei _.
1:Aquifer Recharge .0 Grmindwater Remediatirm
i119-:SAND7CiVAYMPACk(irilifiliadilW7.=._=___."2.7_73..1"---7:7...a7„:_-1_. . .
- OAquifer Storage and Recovery 0 Salinity Barrier FROM TO: MATERIAL •zmeucEmurrrerraoi; • •
OAquifer Test OStorratvatelDrainage ft.
OExperimental Technology OSubtidence Control ft. , ft.
0 Geothermal(Closed Loop) OTraCer Ir..%201D ' GIDG:(11fac'll'idalticTriairalreitiifsecessaryr1-'777-7-----_::
FROM TO. _ . DESCRIPTION(color,hardness,iouirook tyge,grain sin,etc.)
OGeothermal aleating/Ccioling Return) OOther(explainlinder#21 Remarks) r Date Well Started 'I;. :,7-5.- 6•514.10" 0 ft. bo ft. -. l c0 ' / 04/64A
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. . 4.Date Well(s)Completed:. ,/,Q,.., `S/Well 10#440 03 q 600. •I ye-
52.Well Location: , Phorie 4Pt 116.. 4 g q,ssIsit Iciot. ,3s-ort. ty,as .freciz _ _ 100 ,
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7r4o_ Aye/..... lV 14A_. tt_:-wI- e,.r
Ficlty/OWnerName !fcitYlAt Cilic9hbi / ' Pi efSolOey aI4
s•. - 3i Ed , born _ _
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Physical Address,City,and iip alip134 ft. ft.
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• . _ . g2V: C.1_17,74171.:217.L.-_-;:-..--:=1-:7_17---_-_.:::::17._-___..--.7=_-.1-` ---I - . ,County Parcel IdentifiestionNo.(PIN) . - infr --gOROVIr -&Ae- .00+- _ - - - _ It'. •
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'.-. Sb.Latitude and longitude in degrees/minutes/seconds or decline-1 degrees:, ,• (if well field,one 1st/long is sufficient) 22.Certification: ...16.
• . •• ' 3 C'''' I IP. all gig 6 N - it .1'if
al . 6 -)' w
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• ..WeliContrienn ' Date
6.Is(are)the well(s):)6,ermanent or OTeMporary -,
• filo lh C R'„ By signing Ai e form,I heathy cerabi that the wen(e)was(were)'cOnstizeetedin accordance with ro
7.Is this a repair to an existing well: O ;. )Yes ;Ur 1I'To ' 15d NCAC 02C.0100 or 15A MAC'02C.0200•Well Conitruction,Standardt andthat a copy
If this Lea repair,filleat latCwn well construction information and explcrlit the nature of the °Phis record has been Provided to filewr-itowner•
repair under#21 remarks section or on the back of this form. ....-
• 23.Site diagram or additional'Well details:
• - - - You may use the back of this page to provide'additional well constructioninfo r3
8.For Geoprobe/DPT or'Closed-Loop Geothernial Wells haVirigthe'seine N
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'ituiteitiancs Box).You may also attach.additkinal pages if necessary. cra
drilled:
• t , 0 24.SUBMITTAL INSTRUCTIONS .P
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9.Total well depth below land surface: /9 fro _ _ _ (ft.).- (f
- Subinit,thit GW-J.vvithizi 30 days of well completiOn per the following
For inulttple wells no all depths if different(example-3(400 crtull.41000)) .
• „ , 24a: For AI Wells; Original form to Divided of Water Resources (DWR)
10.Static water-level below top of casing: 7 0 (- -0,) lecumatidn T'itcesii4gUnit,1617 MSC;Raleigh,NC 276994617, ,
If water level is above casing,use"+"
11.Borehole diameter: 6 „. ,
(111.)13it Off:_57,_fss _ 24b:For InjectiOnMells:Copy te DWR,Underground Injectirin Cantrell(IUC)
Program,1636 MSC,,Raleigh;NC 276994636 5 . •
12.Well construction method: ai/ io 4,1 ' -- 24c.ForWater Supply and Open-Loop GeothertialReturii Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) ' county einvitonnitintal health department of the dounty where installed
FOR.WATER SUPPLY WELLS ONLY: :y • 1 24d.For,WaterWelLs.prOducing over 100,000 dril copy-to bin,CCPCUA
. I ;Penni&Program,1611 MSC,Raleigh,NC 27699-1611. . •. l
13a.Yield(gpm) /,.). Method of test: if ii.,v _AI r - . :-,1
70% hth .,.„ .,:4 : Date'Site Visited: .),..r2t.2 if ,
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. 13b.Disinfection type: Arriountt_._- 557 _ f:.? • Site Visited By:. . .._,446 . ,
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Form GW-1 North Carolina DepartMent of Environmental Quality-Division of WaterResource.f Revised•6-6-2018 . •:
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