GW1--02291_Well Construction - GW1_20240410

LL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .�
1.Well Contractor/ a Information:Qio y� y� L j
l 7JU y II,.J (l� + pymmE, 11AJ// ) t5.1k,WATER=ZONES c.:tivezilFJ.k;;.": bc.-S-.i:;.1.i. ".a•:'.:.,`C_-_-=-i:1. i._....$'.'t
Well Contractor Name FROM ft TO ft DESCRIPTION
Lis' S • )71 1b C FM c e r '43'
ft. ft.
NC Well Contactor Certification Number l'15:OUTER'Ct1SIl`IG'(foi'multi:sssodsti'eIl4):ORLIN R(ifgpllica'tile;=
Yadkin Well Company, Inc. FROM To DIAMETER THICKNESS MATERIAL - i
ft it ; in. e,
CompanyName '
glaI NNERTASING:OR:TUBING(g'e itlieiiiiii r3osen6-60)1!;'�.�.�---- w'_=:i a`0)
2.Well Construction Permit#:INS t"�p\l , r 0 70 �T - o 2 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comuy,State,Variance,eta) 4. 1 R. 33 it
l�j_ Y� 6 D -2\ Pv G
3.Well Use(check well use): ft. it in.
Water Supply Well: ri.7Z ffaEI'l.'•�..: : ...,—'-.7—' `_ ::-._—_—__-
PP y FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) l esidential Water Supply(single) ft ft. in. '
❑Industrial/Commercial ❑Residential Water Supply(shared) r- .,..-"....r.,- .----.--__...!,-____.—_.._-.__-.,...---_-----..__ -_
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply Well: 0 ft. 3a it- 3erCtu9S ercVi47 -.0b Bqgs
OMonitoring DRecovery ft. ft. .
Injection Well: ft. ft. '
❑Aquifer Recharge ID Groundwater Remediation .r. .
i.'19..SA1ND/GRAYEPPAGK'Cif applicable) �_11—.;_:�_.:°a•'. Y.---."_, -':_ •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD '
DAquifer Test ❑Stormwater Drainage ft. ft. .
❑Experimental Technology ❑Subsidence Control ft ft. '
OGeothermal(Closed Loop) , ❑Tracer 2Qi lUt1T INGZ'O"G'(attachsddiiiiiirilrslieetildf:rieceuary)�, ..:=:�� -`.." = •,
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/feattype, sire etc.) .
Date Well Started 3" ,a-. ti 0 f`. 19 ft 60%1 V
4.Date Well(s)Completed:3 a.5.P t Well B)#A,Ant-O g 2 i g' ft. . 2 F9�ft 1 `,to 7-, .
5a Well Location: Phone#: CIO/-.-��!-,S5 S'2 ft d, ft 1`' '-� L.
S..'It—r`lr` :- .
- saee6• peL.x1 ,I�rek.riVa1.5 ft. ft APR 1. 0 ?fi74
Facility/OwnerName Facility ID#(if applicable) ft. ft . . .
ft ft 1 n L;7, ',6
Physical Address,City,and Zip ft ft •
Yk t let.rV .• . 021::, KSCZw .0,. �..=". �:��Q.: w-" �. _-:_- _�-' , .
County Parcel Identification No.(PIN) Weil O 6 /-1-r fi 6 aft (-g WCT .J.hC' r('.— '
Sb.Latitude and longitude in degrees/minnteslseconds or decimal degrees: , .
(if well field,one lat/long is sufficient) V 22.Certification: • ' _
' N RO e C-4
6.Is(are)the well(s): DPermanent or OTemporary
Si tune o ertified Well ontractor Dale
By signing this form,I hereby certifythat.thewel(s)was(were)colutructedinaccordancewith
7.Is this a repair to an existing well: ❑Yes or l'JNo ISA NCr1C 02C.0I00 or 114NCAC D2C.0200 Well 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 lathe welliowner.
repair under#2l remarks section or on the back of this fond. 23.Site diagram or additional well details: 64
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. (t
drilled: ' 1'
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: If a - (ft) ' '' P•
For multiple wells list all depths D.-different erenr(example-3Q200'and 2QI00) Submit this GW-1 within 30 days of well completion per the following:
I 24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: I I (ft•) Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
If water level isaboveF%',I `use
';sir. ... .,+,.
e'• ;� i 11__ ,t 1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(ItJC)
11.Borehole dram c=s;'.?•?' (in.)B It Off: (Q•UL U Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:A✓.p..),0,,' .D'ft 1 II 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push;etc:) >:i'.,;1 t;:; r
county environmental health department of the county where installed 0
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: / 1
®j,r' Permit Program,1611 MSC,Raleigh,;NC 27699-1611
41
c Date Site Visited: '. •'.
13b.Disinfection type: 70% hth Amount: 13 oz Site Visited By: I
Fomi GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Reviied 6-6-2018