GW1--01669_Well Construction - GW1_20240313

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ft
' 1.Well Contractor Infor,,-tign:
J®-J y - 1 / g 'arm_ IA )V.5 �� 1c14 Wi1TFI`ZONES,S,`;1CS.: yr 1i;.-•'4S%::e:�';n".i:;.1.a:.=_27;c`_1i�.7.:._- ,.=_:'.dam::. .
ai 11 FROM TO - DESCRIPTION
Well Contractor Name �ft �. ft �`�� d
. 5 4 ft.
NC Well Contractor Certification Number "`
w154017TER"CASING;(foi multi=casedMelli)':OR.7: R(itif.'livable)`
Yadkin Well Company, Inc. FROM To DIAMETER _ THICKNESS MATERIAL
ft. ft. Iin.
Company Name
�,g (/� • .16EINNER'CAS NG:OR:TIIBING(eotlieThili closed•:aop)z!f '-=:`�A`--.�.•;...:
2.Well Construction Permit#: 2-LN 2- 3 -[ I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4 1 ft. a 0 ft 6Al 5 in. Sit../r 8 p v C`
3.Well Use(check well use): - ft. ft in. L d
Water Supply Well: blZ SeIZFF��I�-_•---•--___..-.__�: - �Y-._------�:»_1.:---�--_:
PP Y FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft la.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) - ., ft, ft in.
Dlndustrial/Commercial DResidential Water Supply(shared) :•
18:.GROIIT� ` ----� -
❑In-igation ❑Wells>100,000 GPD FROM • TO • MATERIAL i EMPLACEMENTME.THOD&AMOUNT
Non-Water Supply Well: aft .' ft em.ter fl (ela�'1�J 13Mir
13
❑Monitoring DRecovery ft • ft.
Injection Well: S ft ft
❑Aquifer Recharge DGroundwater Remediation _ _
'_19 SAIRU/GRAVELYAC&'Cif applicable)'"----___._._.�-_--_-.- - ----A r
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL- EMPI,ATHOD
' ❑AquiferTeat ❑StormwaterDrainage .ft. • . ft ". � ! r ,� .['Experimental Technology ❑Subsidence Control ft IL. VAR
n ^
DGeothennal(Closed Loop) ❑Tracer 20DRITSNG'LOG'(attachditionul'"sb'eets`iLnecessary)��'-�`a���. Cf.2_�_
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) �+ Q 1 hardness,
7i;teD ?tC n i
•Date Well Started GT.'O d`.` ' o ft. ft aye i ..., i. 4,2 ,,.
�P� r�� . ft ft. GIVCJu:0J
. 4.Date Well(s)Completed:01.'�1.7 If WeII ID#r / O A, )i
•
5a.Well Location: Phone#: 4 tii a 3-.142.. () ft ft 5 �� 1 OsJk•0:� °. . ., •
i ft 1 as ft. �'9r ,,°1y'
Facili OwnerName Facility BM(if applicable). /0 6 ft 14 Lib ft. -s o f,i-q'i Peek•e a i ,�'' • .
WaW�. L.1 vJo • ZI--S i /LIN1, bti.® ft Neal ems' SD'F f jPa,"i' -i
Physical Address,City,and Zip , P4C j t 6(1( f• 7 u e� ft. ^5 .t ,9 fa, It'. ; �___.:__. _
As L•21:RF.Mi7,R ,...�__ ..�_...._�..,._�"- _._. .�___: ____'-__ ':, .
• County:' • Parcel Identification No.(PIN). No o f 100 e1e Sw-t i)r, Wettr /0 A e .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Held,one lat/long is sufficient) 22.C tification: �o
3-L ® .2` '.2o" N 0 g1 a 3Z S'�, . w ' e ®.a -O9J211
6.Is(are)the well(s): Permanent or OTemporary Si ofC edWellContractor Date
. ' By'siguingthisfonn.Ihereby certify that the well(s)was(were)constructed in accordance with 0,'
7.Is this a repair to an existing well: ❑Yes or o 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 arfd explain the nature of the of this record has beenprovided to the well owner.
repair'tinder#21 remarks section or on the back of this faun. •
23:Site diagram or additional well details:
8.For Geoprolie/DPT or Closed-Loop Geothermal Wells having the same You t use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ® (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR), `9)
10.Static water level below top of casing: l t (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 0 `11 •
11.Borehole diameter: (in,)Blt Off: Li , lrr 6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 ..9.)
12.Well construction method: O't f r U I 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 !
° Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a:Yield(gpm) U . 2- 5 Method of test: ('1 of ad
o Date Site Visited: 5/ 9l 3
. 13b.Disinfection type: 70�0 hth Amount: 2-V OZ Site Visited By: I
Form OW-1 , North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018