GW1--02290_Well Construction - GW1_20240410

W L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well ontlactor Information ,� J
�j 1� I �l1 1/ts3%.40, �14::wATE1,YZONES'l� zS >.:.-_._. ea'ia.f�, -2>.,u t•<"�
Well Contractor Name M FROM TO(O L DESCRIPTION' _r A
ft. 1 CIO ft. 33p,� �PI�„f a✓*ems
� 566- p ft. ; ft 1
NC Well Contractor Certification Number 115 01TITICCASING:(f6Ymulti;cased':svelli):OR'LINERAifilf licable)L 7f..:`:;:U
Yadkin Well Company, Inc. FROM TO [DI DIAMETER [TRXCKNESS MATERIAL
Company Name - P ft. / 01a IL O u i t S-in. SDR4 Z I U V C
®/ �y "1165IINNERCASING:OR�TUBING icittiermalacirs dlaop�r_..�:.-_ -__ s:.r-
2.Well Construction Permit#: �SO1'�/i� FROM TO DIAMETER THICKNESS MATERIAL • '1
List all applicable well construction permits(Li UIC,Couny,State Variance,etc.) ft. ft S'J!'9
3.Well Use(check well use): ft. it in.
W�,�ter Supply Well: FROM TO DIAMETER SLOT SIZE` THICKNESS MATERIAL
N7Agricultural Li/tir-•+-C- ❑Municipal/Public ft. ft In. -
• ❑Geothermal(Heating/Cooling Supply) t'sidentiai Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) _--_.._ _. _-•--r _,. _ -----• -- - - _ .
•
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. E141PLACEME TMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 2-5 ft r1. r,e ci,ill fin,- /V!
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft '
❑Aquifer Recharge .❑GroundwaterRemediation _ �_�_-_.__r i,119YSAND/GRAVE1r'PACK'(tfapplicable)L w--_.--.--_._"�____.�._;_-
' ❑Aquifer Storage and Recovery • ❑SaliniityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fr. ft '
, ❑Experimental Technology ❑Subsidence Control ft. ft • .
❑Geothermal(Closed Loop) ❑Tracer _201-DRIP:Y71HGI:OG'(iittach additional she'ete ff.necessary)
FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
• ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. J it. ,A
Date Well Started ((1,' I-1-7-4 J� /•� ,c� -
4.DateWell(s)Completed: ®r`r".asp.` 4 WellID#AAVC°O.3' (�4 ft. 8 7 ft L�0 S( 544 V nl'�, �,y .
5a.Well Location: Phone#: a d _ -4 Z2 cl ft. 1 [ ft rG„A r'-f e • _1 _ ,--,11--.-, f.:,, a .
�p� O ,- .{i,.,. '4d 'l.
,�+ i r9 0 id il�e'.9d�. U) ft. [ -Z-L it. 'S o r' 1- r/M t 4'�."� •
'6®.��d1� � � u r1 ,
Facility/CwneiName Facility III#(if applicable) ft. ft . •QPR .1 O. tfi-Z4
ft. ft
l ,1 3:1 Aaase r' 144 aeo pi N)C.- ft. ft t ;C.it,^•' 1 1_�
Physical Address,-City,and Zip �1®I� -f __ _ —n `':"••' ,-
, G21%I2RMARKR���
County • . Parcel Identification No.(P1N) - t•, ti_t i' '!- .
r_, , •
•' Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one 1at/long is sr fiicient) 22 Cer I cation:
6 . 2 I 1 2< N <� a '1, g 2 S w _ _I...' J:,./ �/ • •03-2 2 2,�
•
c- a of C : ed Well Contractor Date
. • 6.Is(are)the well(s): 126ermanent or ❑Temporary jl
By signing this ann,Thereby certify that the well(s)was(were)eonstructed in accordance with
7.Is this a repair to an existing well: DYes or No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy .-
Ifthis is q 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:
8.For Geo robe/DPT or Closed-Loo 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.
3.
drilled: ® 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days-of well completion per the following: M
For multiple wells Iist all depths if different(example-3©200'and 2Qa 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Bit Off: 6 l"r) Program,1636 MSC,Raleigh,NC 27699-1636
- 12.Well construction method: • a t r IL I_fiki y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 ...
3 Permit Program,1611 MSC,Raleigh,NC 27699-1611 ` '
13a.Yield(gpm) ��� Method of test: a t l� 5� eta 4.•
o Date Site Visited: S,-2.9' � ,1.70/o hth Site Visited B r
13b.Disinfection type: Amount: OZ Y na''WILL
Ferns GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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