GW1--01737_Well Construction - GW1_20240315

=SWELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
'Ina Contractor Information: f.P1'
jCAW1•CS (464ll w14 WATERZONES. .
FROM TO DESCRIPTION
WellContractarName •
100 ft' IU ft 140- ' dr*s+•✓ or% uo' rya nor S
' I6 to A ft. ft , ,
NC Well Contractor Certification Number
1.15i OUTER CASING(fo mnliVeased'vieIl+)DRLINF_Rdf ap lrciible):.,--- _-- o
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. • orf.
Company Name fit Q' i 16:II�ILVERCefSIIdG;OR'TQBING:(geotHermaLdo�ed=loop)"--=--- --
2.Well Construction Permit f/ 6 v FROM TO DIAMETER TBICKNEss MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) "LIt i') ft C .?2 C in.
S di 2 r la Y L l'•
ft. ft in. th
3.Well Use(check well use):
Water Supply Well: aYTaSG>
FROM TO DIAMEIb SLO THIS MATERIAL
❑ ❑ clpaUPubIic ft f// 7
❑Geothermal(Heating/Cooling Supply) '@Residential Water Supply(single) ft �ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) a.18i;GROUT' - - ' - - .. . . . ..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL E5tPLACEIVIENTMETHOD& O•INT
Nan-Water Supply Well: 0ft _
❑Monitoring ❑Recovery ft. ft.
Injection Well: • ft. ft •
❑Aquifer Recharge ❑Groundwater Remediation I'19.SAND/GRAVEL ACIC(rf zplilicable:__ - . _ . -_..
.. _
❑Aquifer Storage and Recovery ❑SalrnityBarrier FROM TO MA EMPLAas .5• TROD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer :13 - :=GLOG(attach ad tlonaValieeta if'tieceuacy). _- ..___ - - - - .
FROM TO DESCRIPTION(color,hadness,soillrocktyp etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) ,- c
Date Well Started '5 —4— 2 1 ® 4.a 2 0 t. I1 Juf t �f'" , �/ rot t`�+
4.Date Well(s)Completed: 3..S'— 2 `Z Well ID# •."'_? 1,-h oft- lye ft. `1 f�g•N i 1/'te G te- J O
5a W.i Location: Phone#: 6,-5G1 4 ' Odit 1 M2. ft. krla, �/p�L Lam- se#1-. -
j /j� �I_ CA) ft. it. _ j
•. ft
:. /OivnaiNam ct t „ Facility ID#(if ap cable) ft tl `L-- a e'
3 a.S 41A11 i i"Lani att , ftft. f� MAR1.. 2024
PhysicaIAddress,City,and Zip Na avow, -
-44'A. 21:RFM'ARXS.... - .1rk,',.,.;..,;;r� P:-.,..cn..nty'�r.k.-
DVliQinOG
County Parcel Ll►ntiftcationNo.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
16 fl 5,9'f' N f/ /, (7q..9' W 3-5-2�(
Signature of Certified Well Contractor Date ,
6.Is(are)the well(s): I i•ermanent or OTemporary h--
By signing this form,Ihereby cern),that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: s T or j'To �� e. 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy Cu
If this is a repair,fill out known well construe'• ation explai fie natu of th of this record has been provided to the well owner. Jo
repair under#21 remarks section or on the back of this form. 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 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: ► 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 132' (ft) Submit this GW 1 within 30 days of well completion per the following:
For multple wells list all depths if different(example-3(g200'and 266100)
4 pp�� 2,g t.4 24a. For All Wells: Original form to Division of Water Resources'(DWR),
10.Static water level below top of casing: lJ (B'•) Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617 • -
If water level is above casing,use"+" 3/5f Z`r
24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC)
1L Borehole diameter:_ Co. (m)131t Off:s.q 3 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: IA 9 Yr 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the countywhere installed :-,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD: Copy to EMIR,CCPCUA
( Permit Program,1611 MSC,Raleigh,NC 27699-1611 -
13a.Yield(gpm) Method of test: 4d V p� )j -i
o Date Site Visited: t/C,4- ,y —2
. 13b.Disinfection type: 7O�o hth 1 OZ Site Visited By:
Amount: ,
•.>_GW=1 a North CarelinLD_enarinrent Ot Envjamuental Ooality—Division of'.Water Resources Revised.6,6-2018___-_