GW1--01667_Well Construction - GW1_20240313

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.,Wel Contractor Information:
. I -1or 1,;_.
. (-Gs.t.�t.. ti4 WA1 ZONE "- r, t
�//1 �,te- S''1� ..:=5:•?741I�vv� v'v�``'t.",. S:.3-WgS V..5`i1 :Y:ti.5e :
FROM TO DESCRIPTION �/
Well Contractor Name ?p ft. 7 ft I `D e1•1, f 1 5-0 6-q��soft I c
3 S^K U ' 27 6 ft• Y7 ft ( a. �`
7 '
NC Well Contractor Certification Number 3540UTF:H:C;ASING.(fur`multi;'cased.sv"ells): RII3ER°(IfaP'lic"able)t--�t";?0="-')'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. , 'in.
' Company Name �' "' iW `z.
�j iL16INNkT2CASING:OR'1'UB1NG;(gedthermal"closedloop)
2.Well Construction Permit it: A 3'g. (6'/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,Comity,State,Variance,etc.) 4 I ft. 11Ij ft. f 2 in- 1
I it?
C.J c j--st j 1
ft. D n[- ft. ® us/1, in.
3.Well Use(check well use):
T
Water Supply Well: FROM • TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. ' in
❑Indrrstriai/Commercial ❑Residential Water Supply(shared) - -,5-----------,--,-7 ;---- .;' '
pP y :18 GRODTC' _,_
❑Irrigation ❑Wells>100,000 GPD FROM TO r� MATER/AL EMPLACKMHN• T METHOD&AMilliir p
Non-Water Supply m(Well: 6 R' f t pop 4'1b p d 2, f(.i rt 9/b'aa.1�• 1 k
❑Monitoring ElRecovery ft. - ft. S a IA
Injection Well: ft. ft r
❑Aquifer Recharge .❑GroundwaterRemediation e. wTvA 9ik SIkrf7 E
i'r191 SAND/GI AVEI't.P.A.CM;(rf 1p-pi )'� ' M1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLAC▪ ENIDIT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology °Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20:1=tNGI:oG`(a"i+ar addlii nal'sheetiliLnecessary) _ - - �..-..
FROM TO DESCRIPTION(color,hardness,solllroek type,grain size,etc.)
❑Geothermal(Heating/Cooliri Return) ❑Other(explain under#21 Remarks)
Date Well Started I--J`9.41 �} 0. ft. Lill ft. '
4.Date Well(s)Completed: 1.t1'24 Well ID P s 9O� �� ft. 1 �3 it G ��/ d-,, e'
Phone#:Y2td.]014-O�6 ft. i ft
5a.Well Location: "�"
C/• /� p, ft ft. ;r`:,d / ' „Y ,
r)ss Ve>iC�,, lrt tsl B.r &V&A it. ft . ;, . �L it a�
Facili /OwnerName / FacilitylD#(ifapplicable) A nn l
AQ s (� g e►� B fL •
ft.. P r- 1 11 4U24.,.
'' .�1..�k9 '1��.,. r , 1.�rgyoth Ad. .d�i ..t 0M's�& ft. ft, h1,Zir�t :i:
PhysmalAddress`City and Zip• Q1 ��� `w+ i r .` ,
.. ' 31to 340 to
k2L°RFMARKS'Er. ...:....., :5;..:..�Psri 'L_3.]C:_.._ . _:._7,_i
County . . Parcel Identification No:(PIN)
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification '
'.-3 6, O 7 7 k8 N ,802. ®,3 6 8 W 1 =12-`a Li
• Signature of Certified Well Contractor, Date
6:Is(are)the well(s): Permanent or OTemporary
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )1fls10
15A NCAC 02C.0100 or ISA NCAC 02C,:0200 Well Construction Standards and that a copy ciri
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the;well owner.
repair under#21 re idrla section or on the back of this form. .1!
additional23.Site diagram or 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: r 24.SIIBM1TTAL INSTRUCTIONS
9.Total well depth below land surface: 1 IJ 2 ` (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-4@200'and 2Q1000
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level-below top of casing: ® (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 I
If water level is above casing,use"+"
24b.For Injection Wells:Copy:to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)I3'►t Off:5-11 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AI f f a {Rr)r 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 g
FOB:WATER SUPP ONLY: 24d.For Water Wells producing over 100,000 GPO:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ir1 tX I,-
77o"o huh OZ Date Site Visited: 7/20 /a_S
. 13b.Disinfection type: Amount: Site Visited By:use9 (�a /�_
CS n5 ( g�a . 7s 14. Or►1 I'f� (��l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018