GW1--01709_Well Construction - GW1_20240315

eWELL C,ONSTRUCTION RECORD (G9V-11 For Internal Use Only:
1.Well Contractor Information: I 1
Co I ii5 +- 11 14c,WA11ItZONES`;d_ :`_',`_ =.T s:_ _ <��_� _`
w FROM TO DESCRIPTION
Well Contractor Name • q0 ft. pl`. ft fi-•_ I.cc -wc Sa &Ri/�ryng
5 195 ft. ,• ` ft. 1.1! ` �q
NC Well Contractor Certification Number n51.OIITFR::CASING(famulti=c"e`sed'irelECORLINF�R.(if`i i'licati 1-�"lell" .;:-?'•' ,✓
Yadkin Well Company, Inc. FROM TO DIADtETERI THICK/MESS 1 MATERIAL
• ft. ft • I in.
CompanyNamc 004.me �' Stet- Zyg'-•2.3CO '.sI61INNEECCASING:011:TDBING:(RedtHe•¢islclnsed:16 .-_ -- ,
' 2.Well Construction Permit#: IA/ 2.1 -042. -S-9 FROM TO . maMETRR THICKNESS MATERIAL
List all applicable wall cansiructionperniits(xe.UIC,Comity,State,Variance,etc) I ft 63 ft to 5ff 1 s,60 &Alt S i-t_t I
ft ft 1 in.
3.Well Use(check well use): _ - - -- •-- -_._-- _---- _ ---..-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
' ' DAgricultural ❑Municipal/Public ft ft in.
['Geothermal(Heating/Cooling Supply) ❑Residenfial Water Supply(single) it ft in.
' ❑Industrial/Commercial ❑Residential Water Supply(shared) :718,G1tbD _- ... -- �_• --
rigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 2,1 ft J ,M,C-.h;f.3 gVO. JI 1)1 •5
OMonitoring ❑Recovery ft. ft I
Injection Well: ft. ft
❑AquiferRechazge ❑GroundwaterRemediation 1:719:-.SAND/GRAY A:TA.C{ira lmccable)_,_ _. -';-- - --
• ❑Aquifer Storage and Recovery ❑SvlinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft
• ❑Experimental Technology ❑Subsidence Control ft. ft
OGeothermal(Closed Loop) ['Tracer C201DItI)TRIGIAG:(a"ttacliaddi8onal'shee5ifuecessa"r`y)_.J._.:_,_-_______-_
FROM TO . DESCRIPTION(eider,hardness,soli/rock type,grain sire,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ��' ft %
Date Well Started A =d'
4.Date Well(s)Completed: I ' Well ID# AA Q a©It. so ft •Po0�ft Cal Si"
•
Phone#:11 r4-(c W- 2.33 ft. 1 ft c� F..,_.; •,:., ,
. 5a.Well Location: y\( '�l,�, -- t•1...,t, P'_i 1 ; :i
ft ft
(• Facility/OwnerName Facility ID#(if applicable) ft. ft. t. z U z4
f. ft tntC:i ii7l:is !7 .; :d^..:.,.
• orb Dog(:u Gt+�► c'T. �.!/1Cs(Gr e d f'fi�/� mC.rs&e�+an ft. ft b
/ � G;Ssi�.i�;ZE;
Physical Address,City,and Zip ,,_,_-._-- ---__ -- _-_---
lJ 1i'2s•lr+�Si C',t� ) L`d(1"+%'
�.h Parcel Identi ficationNo.(PIN) ,
i , 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
a,-.I.1).,11 ,..‹
S tore of ertified Well Contractor I Date :
6.Ware)the well(s): ❑Permanent or ❑Temporary J l
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance withA.
7.Is this a repair to an existing well: DYes or `l lNo -., ISA NCAC 02C-0100 or 1SA NCAC 02C.0200 Well Conshvction 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. 23.Site diagram or additional well details:
eoproe orClosed-Loop You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT Geothermal Wells having the same
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.
ITo
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10 (ft') Submit this GW-1 within 30 days lof well completion per the following:
• For multiple wells list all depths if different(example-3Q200'and 2®100') 7
�p 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: -"4.J (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
,� 24b.For Injection-Wells:Copy t I DWR,Underground Injection Control(IUC)
11.Borehole diameter: •
(in•)$It Off: •`7�{'� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai" p,,4-4e.y en 24c.For Water Supply and Op 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
13a.Yield(gpm) 0 Method of test: pI Permit Program,1611 MSC,Raleigh,NC 27699-1611
• I.
o Date Site Visited:3--I Ci-12.3
13b.Disinfection type:
70/a hth Mount: OZ Site Visited By: a s .
•
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018