GW1--01693_Well Construction - GW1_20240315

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___SPELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
Information: 1 . �/ �� 1 I `'N
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' (1J(Y •�( '( I 1 :a�`-`• 1 � � I I ' `' /" r4t'WA` `7ANE5`•'`sox_:,';'!-':,.t:?'I C •. -.,n,r i' _., .,. ..; •. , ,.. (f -
LL j FROM TO ' DESCRIPTION
Wert Conttr,ctorNa= q t"ft ft 5 c eI II
NC Well Contractor Certification Numb er ,, �•^
is Li'bUTEI;`:G�ASIIVG''(formnlli°e' '�:weIIs)`:ORX,II1�lt;(i�a""li�le�'�7 ty::". e
Yadkin Well Company, Inc. FROM TO D TTmcKNESS MATP:RIAT P
e{- I f• 11I ft /.Qi6-S ;in. (v -1.( !' VC.
Company Name c l�� ..,',";,,:d.c.,..•r: : .
-'�r16s1NNER;(tACiNG:OR',Ti7BINGf(geuthei•�alcln's'ed=lodP�-'�.:�.:. - _e. _ '•;
2.Well Construction Permit#: P( W , 2022 V 00 m qq FROM TO . DIAMETER. TSICRNFSS MATERIAL
List all applicable well constructionpesntits(i.e.UIC,Camay,State,Variance,eta) . ft, It, IilL
3.Well Use(check well use): ft ft in.
ZS'.:CW41;a'sFi;` is i.,r...;;.. , 711"1:>i f:':"s;r.. :::::. ': :::1 _n_:. "m` `'!'.:
Water Supply Well: • FROM TO DIAMETER. ,SLOT SIZE THICtO`1FSS MATERIAL
❑Agricu1tu al ❑Municipai/Public ft it in.
❑Geothermal(Heating/Cooling Supply) ii dential Water Supply(single) ft ft in.' '
• ❑Industrial/Commercial ❑Residential Water Supply(shared) ;ier GRdUT�:- .. . - _ .. :. . ., >1i as
❑Irrigation ❑Wells>100,000 GPI) FROM TOR MATERIAL EMPLACEMENT METEOD&AMOUNT
Non-Water Supply Well: 0 ft' to ft. .t�,,,..r:. Q Chi 10 S i b v,/' •
❑Monitoring ❑Recovery ft. ft '
Injection Well: ft. ft. '
❑A uifer Recharge ❑Groundwater Remediation �,r.`,:..:,,,.-
q g j`19LsAlYD/GR'AVM?'R,Atirtif appli'c"abie")::L," '.- 1._ . ._ •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL �Z FLACEM TTsTEoD - -
❑AquiferTest ❑StormwaterDrainage • ft ft - ' 1
❑Experimental Technology • 0 Subsidence Control ft. ft"
❑Geothermal(Closed Loop) OTracer i':20'.DRtC1iI G-1.;OG(a"ttaeh da7itiionaI'sheet£iieceissry)i. `,:".=.-:7-n :'="t'l•
FROM . TO DESCRIPTION(color.hardness,sell/rock type,erainsize etc.)
❑Geothermal(Heating/CoolingReturn) ,p Other(explain under#21Remarks)
Date Well Started 'Of —IL`1-."( g� 0 ft' 1 5 ft C i.r, ':4-:
4.Date Well 1.;s)Completed: 7(6- 1) Well ID#�/\Q"Ori�ft 6 ft 'S}'g ft ,1
Phone#: ��A�- r'�' 9 R' 4 ft €
t ` r ' e •
.5a.Well Location 1 ds. t,
ft. ft
,yy��
Facility/OwnerNime Facility ID#(if applicable) ft ft i _ ,,. 1.
/�it
!l 0 CadIe�•if e y rl'& AIL'Af ft ft , i -t k„:L°'L...[' A+' r.:tad •
Physical Address,Cily,and Zip p �g �]�ry� ft ft. MAR 1 5 702A.
•
Su lr V''I, l "f U-.y�a"��CO� U(.JpRF.1VY2?NY(F.: ., .., ,:5: .. .._...:' .-..:�-�'.l'!-t. J
County Parcel ldentification No.(PIN) . I lri5,riY:.rd^R?!'"'r 1,21f;l'Unlf
5b.Latitude and longitude in degrees!minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 1.,I. 22, f" ..cation:
. &'J 2X3 N 20, % /6S W �i ,I id. f.-4.,.,Q egb .'
6.Is(are)thewell(s): Qmanent or ❑Temporary '' p Si a of edified ell Contractor:'
���tm�'® By si: Mg this fort 1 hereby certify that the Well(s)was were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ali `°`��" 15A NCAC 02C.i100 or ISA NCAC 026.0200 Well Construction Standards and tat 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 render#21 remark section or on the back of this form. 23.Site diagram or additional well details: U1
S.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
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construction,only 1(W-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: (ft.) Submit this GW-1 within 30 days bf well completion per the following: q�
For multiple wells list all depths if Afferent(example-3@200'and 2Q100) ` u
�°� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �+ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: C. (m.)Bit Off: 6.,` )SC 24b.For Injection-Wells:Copy to DWR,Underground Injection Control(I(IC) r13
Program,1636 MSC,Raleigh,NC 27699-1636 412
12.Well construction method: t r Z.ea / 24c.For Water Supply and Open1Loop Geothermal Return Wells:Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health deparbnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells pro duciriglover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 ®°® ;,fig -i I$r��s(fl
13a.Yield(gpm) I CD Method of test: ®Yf
Date Site Visited: 2.-1- 6.45 14.4 L.
. 13b.Disinfection type: 70% hth Amount: I 1" OZ Site Visited By: Dom;
'-
1,120:kr ss,,°L( e -Qafarr>f+
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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