GW1--01613_Well Construction - GW1_20240313

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r 'WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: . ': It
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/• -.1.Well.ContractorInformation:
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MAR 2Ut^T
rat e 4QJ11111 Ba c14 WA.1'Eg,zons* . "cS i.,d' v giti ..,-,:v,:• ''t .1 ,; s I N',
FROM TO DESCRIPTION ^ v,11v;C
Well ContractorNad Ml'e ft 9 t j triiO(ii,d.c,• •---. n
. DS 7;1 A .. soft ft d G iti-rdS. Safi' a
NC Well Contractor Certification Number u S OUTER'CASING'(fo%nultc c d:weltii`:ORL1NERs:(ifap'licatiler... , :::.:'7`%:;?'
Yadkin Well Company, Inc. FROM TO• DIAMETER THICKNESS MATERIAL
ft ft I in.
Company Name ;i1GIIVNER!eASING:OR:TUBING•.` lidtliiffffi`:el"Died ififfi -W'- -'` '13,
2.Well Construction Permit#: '0 Li id FROM . TO - DIAMETER THICKNESS , MATERIAL
List all applicable well construction permits(i.e.UK',Coatty,State,Variance,etc.) ft ft in. Sts? */
3.Well Use(check well use): - ft ft. • in.
Water Supply Well , Offri$7432 .rw. •.--,,.---7.-' . , __ -. �`�=::::..,
FROM TO . DIAMETER SLOT SI7.tr THICKNESS MATERIAL
❑Agricultural • ❑Municipal/Public ft. ft
.❑Geothermal(Heating/Cooling Supply) )42.esidential Water Supply(single) ft ft . in.
❑ladustriailCommercial ❑Residential Water Supply(shared)• 18 GRDDT `E" ,r- - - ---
❑lnlgation ' ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft • '
C�1z te.4
1Monitoring ❑Recovery - ft ft t " J
Injection Well: fr. ft . . Pr fs.r'r'a( ly pr 6¢s
❑Aquifer Recharge ❑GroundwaterRemediation • i „
❑Aquifer Storage and Recovery ❑Salinity$arrier i19.SAND/GBAVEli.PyiCr(ifinPiiiihie)' ,`l"- `. -_ ' .'Lu
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft. : -
❑Eicpeiimental Technology ❑Subsidence Control • ft. ft. . ' •
OGeothermal(Closed Loop) ❑Tracer 1T201DRIT IIVGI:OG:(iit aili';additional'"sbeeti f necessary) "-`-"." =
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hnrdaess,so'dlroek type grain size etc.)
Date Well Started ; ® ®9 .. "
4.Date Well(s)Coinpleted: ,,igs4 Well m# /4�'0.3 0 g 5"r4 •
ft. rI 0 t iff4 ei :•Jek r� 5- -(ree A 4
Phone#:33t-rtt- Q,9' .ft ft • F d�
5a.WellLocation: �i'b 41 /ice. '�..e e _ _�617 _era- _,` e
�j 336- 667- Z7-8i1 ft. ft.
oaauel,�'e r()A eed .
Facil ty/OwnerNamee y FacilityID�#(if applicable) ft. ft .
,1-'i j. rushy / P) u 1 I'/ rWl ti >�f is•
R. ft
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Physical Address,City and Zip gi t.iti ft. it _ �.
County Parcel Identification No.(PIN) iy'c et"'t�.,s':'• `. a�' 4/'if a4,B�rf .�• e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ®'of. '1L0''''j 61p6 k" 1�ro� r tt�* •6 e ,
(if well field,one lat/loog is sufficient) 22.Certification: - -�-
36d •lvl6Z - N 1., lZgl® • - w , ,� 711 � ,d V 4P- .
6.Is(are)the well(s): Permanent or .❑Temporary s' `ofC ed Well Contractor., ' Date
l� li By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with' co
• 7.Is this a.repair to an existing well: 'dies or CINo 154 NCAC 02C 0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the S' y of ibis record has been provided to She well owner
repair Under.421 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 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 r i
o
9.Total well depth below land surface: �� - (ft) Submit this GW4 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a3200'chid 2Q100) -
24a. For All Wells: Original forts to Division of Water Resources (DWR), ,
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617. ro
If water level is above casing use"+" 1
,�5 o 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) �
11.Borehole diameter: (in. Bit f 1
` � Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ' If co ' e 7 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
I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) -' Method of test: ri di I - •
70o/n hth Date Site Visited:
13b.Disinfection type: Amount: �� 7 OZ Site Visited By: i
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� �I ` 9,50' 0e& 91Eel q5�
Form GW-1 North Carolina Department ofEn tro at Q ty-Division of Water esources 0�49 3f Revised 6-6-2018
Pri 9.