GW1--02300_Well Construction - GW1_20240410

i
-''a
,":%) ' WF�Li,CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor IVtI$
rmation: i r�OdV_ 12ty WeIrContrt:actorName /FROM nTO�L� DESCRIPTION,_`,� ,tom /,
�V 65 9241 ft Tail ft `f.1 v1 ikJ� 14� &PM (yi -.)
ft. ft
NC Well Contractor Certification Number rta sR ^®
i=15::0UTElL'CASIPIG'(formiilti;cased;welLv):OR'IIIVER;Caf�applica'tile)�"-.._.:�?:.��..
Yadkin Well Company, Inc. FROM TO DIAMETER; THICKNESS ll MATERIAL
ft. ft. ii. 'in.
Company Name !
z 16 INNER:CASING:OR TUBING`(aeothermal:closed=loop): _ . '•
2.Well Construction Permit#: 0 CI. 21 Y, FROM TO ' DIAMETER THICKNESS t MATERIAL
List all applicable well construction permits(I.e.UIC,,Cowity,State,Variance,etc) t' ft. Id S ft )a §' m r-j(U _ cd4 C(o i 0,
f. ft ' Sn•
3.Well Use(check well use):
Water Supply Well: =„ , .. s:17•:S.alititia..y`.— --"7 w K.._.-.._ • ::::i
•
' '; i FROM TO DIAMETER. SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft in. '
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. 1n:'
F.
❑Industrial/Commercial DResidentiaTWater Supply(shared) aa;GROUTra'„'" .: — .:., = - •v" --�
❑Irrigation ❑Wells,>100,000 GPD FROM TO MATERIAL EMPLAC> NTMETHOD&AMOUNT
- Non-Water Supply Well: • 0 ft: '�y( ft. ieh es itiV it Y a y -1361,�J Q
v rJ'V of {[ "j/�
'1 ❑Monitoring ;;1Recovery ft. ft.
xr `' Injection Well: ft. Et
CA
❑Acuifer Recharge ❑Groundwater Remediation a
r i2I9rSAND/GRAY.EDPI.C$.'`Cif:applicable)- _ =._..5.....� ?." _.0 •
fili: ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL , . . LMPLACEM.ENTMETHOD t ,a f''..A
1/r s. ❑Aquifer Test ❑Stormwater Drainage • ft. ft I 1
r
•j ❑73uperi• mental-Technology • ID Subsidence Control ft. ft r V 2024
+/ ❑Geothenmal(Closed Loop) ❑Tracer ?OiX 1 Ii GLOG'(a'ttach additional'sheetszEnecessacy)i.J f i .,..c,
❑Geothermal(Heating/Cooling Return) CI Other(explain under#21•Remarks) FROM TO DESCRIPTION(color;hardness,'soil/rock type gramaze,Ate.) ,'-v ,, ()_
C) ft. If rl t. 50; _.
'7 Date Well Started ; ''�'^� _'lA - -� �
4.Date Well(s)'Completed: 3 iig;;2.1 Wel1ID# ql2r. .//'1 -ft 2.7 ft. ,.:;.e4,, -gIar� 9. I
5a ell Location: Phone#:Il�ttie 3 ,ry g%T T 3. Yz !► S ft. [1,�+Q ft 'Vary ^R'a, �/�'oy!W ~ -
V�8S 1�� 7 ''�.1 �� °'C7C�i�dPv� ft: ft.
••Facility/OwnerN 'e' "` Facility ID#(if applicable) @'� ft.. ft'
9�
., r ft ft.
li physiiccalAddrreesss City aridZip til}6'4 ft: ft
k J K
County; Parcel Identification No.(PIN) it1 TM3- Vic: ��+`t�e� rJt r C7e
SS:Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: � � ��� -
(rfivsll'field,'one latdong is sufficient) . 22.Certification:
3 ( (7 0 ,r•a NRI;3 1 W , / .
6:Is(are)the well(s):,t ermanent or 'OTemporary • Signature ed We on ctor Date
By signing1hisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
:''',..'1.Is this a repair to an existing well: . ❑Yes or ithlo=;;• ISO NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,j111 oil:,Grown well construction itformation and explain the nature of the of this record has been provided to the well owner.
repair underry#21 remdrlr section or an the back of this form. - ,6-
23.Site•diagram or additional well details: . i ,
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same •You may use the back of this page to provide additional well construction info
only (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• construction, nl 1 GW-1 is needed. TOTALNUMBER of wells
drilled: ✓ I, • -
24.SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface: 9A.,Ci (ft-) Submit this GW-1 within 30 days'of well completion,per the following:
For multiple wells list all depths if different(example-3@200'and 2@100) 4
10.Static water level below top of casing: 11042
24a. For All Wells: Original form,to Division of Water:Resources (DWR),
. (ft.) Information Processing Unit,1617 MSC;Raleigh;NC 27699'4617
If water level is above casing,use"+' ,,
�/ ei 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)B It Off: S�U
. _,y 4 G Program,1636 MSC,Raleigh,NC 27699-1636 �
4.f!
12.Well construction method:Al/e'2.J€'4p ©4 M 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc) county environmental health departinent of the county where installed p)
FOR WATER SUPPLY WELLS Ol\LX';,; 24d.For Water Wells producing'over 100,000 GPD: Copy to DWR,CCPCUA
(� `� •
Permit Program,1611 MSC,Raleigh,NC 27699-1611 t •. ro
s
13a.Yield(gpm) 1 Method of test: /14
o �
Date Site Visited: -20-2-;
13b.Disinfection type: 70�o hth Amount: OZ
� Site Visited By: ink ,
Form GW-1 r ___ North Carolina Department of Environmental Quality-Division of Water Resources' �� Revised 6-6-2018