GW1--01638_Well Construction - GW1_20240312

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Wi.,CONSTRUCTION RECORD(GW-11 For Internal Use Only:
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1..Well Contractor Information:/� 3
�P o d-y (�9 11 a A� t ( �, I h t c �r CI14YWATEIZ=ZONES:eV.,,r:�M�a;:r.11 D , �:�s`4.7.r.,1. ..'irli_ _'r;�.... ' 0
Well Contractor Name •FROM TO DESCRIPTION L`1
S 6 6_� • 5 Lf ft,
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NC Well Contractor Certification Number r15:OUTER"CASING(OKiiirIt are.t eie3B)OR '('ifilh-licaZile)" :: - -
M Yadkin Well Company, Inc. ' FR^ I-TO I DIAMETER I T ICKNEss 1 MATERIAL
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Company Name •-
:a16f0NNER:CASING:ORT1B3NG'.eotlierEio1dosed:loop):;-.r'-."--' ':::_::,._._.^.i.
2.Well Construction Permit#: Z Q7 FROM TO DIAMETER TRIMNESS MATERIAL
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List all applicable well construction permits(le.UIC,County,State,Variance,etc.) 4 i ft d tri it 6 e Z<- m• Q2A-z t !'V C j. -
3.Well Use(check well use): ft. ft in.
Water Supply Well: i..7 -MD Ili" .: :_l "'- ---.- �" —.,.:7-------,,7-.7..1S:
FROM - TO DIAMETERSLOT SIZE~ THICKNESS MATERIAL
❑Agricultural ❑M cipai/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in '
Supply❑lndustrial/Commercial ❑Residential Water (shared)_ r1-2-- —___ _ _ __..
❑Irrigation ❑Wells>100,000 GPD FROM TO 'MATERIAL EMPLACEMENTMETHOD&AMOIINT
Non-Water Supply Weil: 6 ft 2.0 ft p a�ntz>teb .,1 0 n 5 Pb
OMonitoring ❑Recovery ft. ft. V' + y
Injection Well: •
❑Aquifer Recharge ,❑Groundwater Remediation 1 ft.ft • j�L l .. .i+1
119'.`SAND/GRAVED'PACK(if;applicab"Ie) ._".: =_•:: a ..La' ,
❑Aquifer Storage and Recovery ` ❑SalinityBarrier FROM TO MATERIAL EMPLAt ENTMETHOD
ft
❑Aquifer Test ❑Stormwater Drainage ft OZ4
❑Experimental Technology ❑Subsidence Control ft. ft - tnicr fria.;'ien p•,---
DGeothennal(Closed Loop) ❑Tracer =201-DRIIXINGLOG'(attsichadditiiiiii sheetsifnecesiary)T-- Li'°,[CC`t?7(__—:.:
FROM TO DESCRIPTION(color,hardness,soli/rack type,grain size,etc.)
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started al-q -Z q �ry et, ft. 3 g ft. f c- Jh d e �'
4.Date Well(s) ( -0 Completed: - /'�� Well Mil ®®. - 3 5 ft. 6 4 ft. 1,ei,e� rem'�c
Sa.WellLocation: Phone#:-30, Z9^(a® 'C <.5 ft ft.
6 25-� t.L 4. ' Staf i t^ram-tom
w.304— 969— 20gt 29,1 ft. ft. /
Facility/Owner Name
�, ( Facility ID#(if applicable) �jt�`�I 1 ft. O ft lc i1- r.ni'a
,/�/42 Old` P-f s. l lt34�a°'ccec-i1L2.'1OJV cols it "ao ft c V(ir'A14'07
Physical Address,City,and 70 1 ft 1 001-ft
" ��d tom _ r� 9A.: Pt
J =~.!' 5fCt 7409-� S2SiR 'ARxc� : , ,/ -:;=
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County Parcel Identification No.(PIN) -. ,
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . - •
(ifweelll field,one let/long is sufficient) 2 ertification: r^J� •
•
1 -6 i -Oci-
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6.Is(are)the well(s): t ermanent or OTemporary Set Lure of Ce ed Well Contractor Date
By signing t form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or f!tTYo ' ISA NCAC 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.
F/' 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: • 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 r GO ft Submit this GW-1 within 30 days of well completion 'ei the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100) ( ) y p p
10.Static water level below top of casing: ti 0 (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 M
11.Borehole diameter: 4 (in)Bit Oft 5 r Pt.Li 24b.For Injection Wells:Copy to DWR,Underground Injection Control([DC)
nn ''.. Program,1636 MSC,Raleigh,NC 27699-1636 '
AIL,-12.Well construction method: 1Gt7 Iris -.
(i.e,auger,rotary,cable,direct push,etc.) 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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
13a.Yield(gpm) �i� Method of test: 0 Permit Program,1611 MSC,Raleigh,NC 27699-1611 �
70% hth Date Site Visited:l/—s-' •� hipe1. 4-",
13b.Disinfection type: Amount:_ 4 S OZ , Site Visited By: ,.1�9'a2 I C-� ( �y
Form GW-L ,.. _ Nodh.CamlinaDenartment,of.Enviranmental Quality-Division of Water Resources Revised 6-6-2018
Price:_ ? '
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