GW1--02298_Well Construction - GW1_20240410

", WELL CONSTRUCTION RECORD (GW- U ® or Internal Use Only:
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, 1-.�Well
'Contractor Informaation: • j P
3 01 wit cr3r �14:WATER'ZONES :. -'5-`i.' .'�.a ..r; 2.n� ';i.t:t :.r' s��"
Well Contractor e • 'FROM TO •...^DESCRIPTION
. P ;G R. ®rt _3 � ;
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®� 7e0" , ej IL 7f4�s1ld f
NC Well Contractor Certification Number J15rOUTERVASING'(16Fmulti-ea Edw`eII6)`0R:13INF (ifif 116 ble)=E ; ,,
Yadkin Well Company, Inc. FROM TO , DIAMETER TRCENESS ] MATERIAL
ft. ft ' in.
Company Name �J � Q 'r.6lINNER.CASING`OR-TUBING'(g iitliermal'r]osed]oop') '__-_-,.�:_.____.
Y/ Oj
2.Well Construction Permit#: v iQ to FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) �/ft. 39 ft 4,d?rla iiz, d _
3.Well Use(check well use): (t ft it 1°'
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Water Supply Well: L17:iSCRZEN"..as;::� _-:-
-.:_'_ ---- --.=.=_==— __--_- _--
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) Its catO'OT' _e...__-__- 1._ __ _ ____ _
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft , ft tJ'QO''( ��a P o,o reJ
[Monitoring ❑Recovery 5• ft. 4 3, rt. &NP.. n.
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Injection Well:
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ft it.
❑Aquifer Recharge . ❑Groundwater Remediation [191SAND/GRAVES:•PA:CI CIiflialicatile)EL:=_-_==__
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD —"`
❑Aquifer Test ❑Stormwater Drainage it, ft - '
❑Experimental Technology ❑Subsidence Control ft. ft • •.
❑Geothermal(Closed Loop) ❑Tracer ,20;DRILTStiG`ZOG:(fittac7iiiaaitio`nilstieetairn`Eensnrq)Lwe==_,____.__w
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO •DESCRIPTION(color,L.rdnns aoll/rock type grain size eta)
Date Well Started 3 1- rid �j - 0 ft' •�b fr' So l .._
4.Date Well(s)Completed: .3 4 v IY Well 1D# Y4# 5 O 7 /6 ft.• / ,fdve L1 e' t /.'lIA6c, Y'`i•, �d
• Phone#:
,3‘-�s'?3' 9 /tea 'peel �Pir
.Sa.Well Lofca/lion:, ft it � a A.-�,
1,Yr. t r
Facility/Owner Name Facility ID#(if applicable) R' ft ��'F''� -r )s x.
VS ra,� f/®ws e i , j'16lerr&.ilt - ft. . . APR. 1 iQ?�
Physical Address,Ci and Zip aaIryci it , ft
• :21:RB5TAR7SE:•... ---- •'--- _---r`.::....,..-'- .��_,,,,. =t- --
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County` Y Parcel ldentificationNo.(PIN) ;kb pa ek —14A vex. 414,, ,,,, ,,s,,..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field;one lat/long is sufficient) 22.Certification:
' 34 1041137
1N gl lei08Sa W
6.Is(are)the well(s): I 'ermanent or ❑Temporary Si id C ,lied Well Contractor Date i.
By signing lhisfonn,'hereby certify that the wells)was(were)constructed in accordance with `�
7.I3 this a repair to an existing well: ❑Yes or .Io ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy ci'1 •-
Ifthis is a repair,fill out known well construction itforntatidn and explain the nature of the of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this form. '
23.Site diagram or additional well details: JD
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. -,1>'
construction,only 1 GW-)is needed. Indicate TOTAL_NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary_
drilled:
s 24.SUBMITTAL INSTRUCTIONS
• 400
9.Total well depth below land surface: -(fL) Submit this GW completion per the following:-1 within 30 days'of wellFor multiplewells list all depths if different(example- 00'and 2QI00)
°'' 24a. For All Wells: Original form to Division of Water Resources (DWR), CA.
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'•+" "µ u
��.��' 24b.For Injection,,Wells:Copy to DWR,Underground Injection Control(IUC)
11.Bor'ehole diameter: tP (in.) -A)° .
® , Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4x-iiiderl tt 24c.For Water Supply and Open-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:M DWR,CCPCUA
13a.Yield(gpm) i Method of test: f/f`/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
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3
13b.Disinfection type: 70% kith Amount: Oz Site VisitedDate SitetBy:a 4/ `�
is
_Fnra+.GW L •. - ------- "_--'-"—lina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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