GW1--01734_Well Construction - GW1_20240315

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: I V
1.Well�Contractor Information:
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.' 4 i d^ L� �� a V.- ca4:WA '7ANE5: , . , i-y;•;; _.i:•sv.,: .u-c::.a::c.:�:... . . - .
FROM TO .• DESCRIPTION
Well Conhacto rNaiae cifs
• ft ft I I b
3 5-4? - ii- ft it.
NC Well Contractor Cer ificationNumber :yri,`'OVSER:CASING'.(fozmtillirrlased:welg:OlalliE1iiC ap licatilef;=t;a
Yadkin Well Company, Inc. PROM TO DIAMETER THICKNESS 'MATERIAL
f. ft. ! !in. g
• Company Name
.,
/{ QQ I63INNER:GASING'ORTQBING:arcthei:marclii titre��•_:=:=:a .;3lii.t �:i`:i• �'
2.Well Construction Permit#: Li o y ®S I FROM TO . _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.17IC County,State,Variance,eta) 4 I ft. ‘a- ft e.2,6`G in* I ITT 4, S41..C. ( Ale/
3.Well Use(check well use): - ft. ft. rn
Water Supply Well: s177SC .�:::..1 Z,.. 1?'_. ....v.a.;.I w�r�•. .,u 4.......iv: .1. ....w.* 1,+ F,
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaiRublic ft. ft in. I Y
❑Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) " ft ft in I '
❑Industrial/Commercial ❑Residential Water Supply(shared) ;wi$'";GRti11T I:tF,.. .:7,4-..cr.-:i.k?G�.. .•• ., �.,•: -
:. n " r� 'I ._ ~ s:<;;+:T'::.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL �} EMPLACEMENT METHOD&AMOUNT [d g 1
Non--Wafer Supply Well: 0 ft' 62 ft. Poe-Poe Pry Stae4Ofr.-„/eA r ht
❑Monitoring ❑Recovery ft. ft 1 3 r 45 f
Injection Well:
❑Aquifer Recharge, •❑Groundwater Remediation ft '
ji•19:.Sb TD/GR'; 2PA2•T.F ('..apjiii Iblez.,.,. .... . '•+
• [Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL EMPLACSnZENPMETHOD ,•
❑Aquifer Test ❑Stormwater Drainage ft. ft '
❑Experimental Technology OSubsidence Control ft ft I
❑Geothermal(Closed Loop) DTracer •201.3RT IIVGIAG.(attacha8ditto`na1'slieefi'id'.ne'cdsary)=a;.ZviF:""'>ref-r'f`:I:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION Ceder,baraness,sell/rack type,grain sire,ern)
_ Date Well Started 9.:•40,-aki 0 ft.• g(2, ft Sell
4.Date Well(s)Completed:�.-a3.-xi WelIA#.44 7 11®7 0._ ft- day .ft (pit . 1-a ` /w�►g 1'C
Phone it:S2)- JO(�- 1Rs p { /
5a wen Location: A;1A 0. ,� �' �fr. ��� it. In-►r� [ ei -.�rah tptot::::.4 r AC
f0(� e^ IZuaz fr. ft a
Faiolity/Owner Name Facility ID#(if applicable) ft ft ' ; ���1 ) 2024
. L-I9 9 � e_..ej tq �/�4 COm/ el, R rt
^�% q ft ft tT:gt.:?ros4:F:1 ;,,;�yg yra
Physical Address,City,tindTap / S. ep3e9� ee6.0 6 )R'{
•
aitiyrAtYifs.' �:... I t r 1„2.1 .'i ll1.+0 i.�ZJ o.,..f'x+.^�'•...5` v ^i4,'1.rx.•'
County , Parcel IdentiticationNo.(PIN) y�Id_ Ir G r / t
Sb Latitude and longitudem degrees/minutes/seconds or decimal degrees: • • ` _ aft" ?oV0 " D) '
if well fief one lat/lo is"Sufficient •
C � '� ) 22.Certifieatioric` .,t �,-,:.
3(2' ob ® 10 11 N ,gl 9 .' '' s- " w • 1-412kk -c! i './c'_._.- - \ -' ‘.2 , it
6.Ts(are)the well($)• ermanent or ❑Temporary Signature of Certified Well Contractors. Date 41.,
By signing this form,Ihereby aerdfy that the well(s).was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or illfo 15A NCAC 02C.0100 or IRA NCAC 02C!0200,WeE Construction Standards and that a copy
If this Is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remark section or on the back°fthlsform.
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 Ito provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( See Over'in Remarks Box).You may also attach additional pages if necessary. -
drilled: i 24.SUBMITTAL INSTRUCTIONS c
9.Total depth below land surface: (ft.) CA
Submit this GW-1 within 30 days of well completion per the followings
For twill ie a wells list all depths if different(example-3Qa 200'and 2Q100) pit,
10.Static water level below tap of casing: SO (ft) 24a. For All Wells: Original form to Division. of Water Resources (DWR), v
Information Processing Unit,1b1T,MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: tl® (in)Bit Off: Ce I PO 24b.For Injection Wells:Copy to DWR,Underground Injection Control(ICIC)
Program,1636 MSC,Raleigh,NC:27699-1636
12.Well construction method: Ail /.a "IC 7 24c.For Water Supply and Opeis-T.,00p Geothermal Return Wells:Copy to the 0
(ie.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) Method of test: p�® /® i
70% hth l Date Site Visited: / -12 I- 42
13b.Disinfection type: Amount: ®• OZ Site Visited By: ME,
t'k - . ,
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_ North Carolina Department of Environmental Quality-Division of Water Resources Revis 6-62018
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