GW1--02301_Well Construction - GW1_20240410

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- - Vrgi,CONSTRUCTION RECORD(GW-11 For Internal Use Only:
'�1.Well Contractor Information: e'•
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�®Ci� v �'34wATE]tZONKS ::_,:'.;7.:` _ Tyr.:':= . �_., _ :.. ,._, _ :_
FROM TO DESCRIPTION
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S.
v/ell Contracts Name
y �/ /04° /171't. 17: th ®.
NC Well Contractor Certification Number = 0)
_15.'OIITERCASIIQG(foi'miilt'rc'es �eli+):OR�IC�ap'lieable)=:�_ -
Yadkin Well Company, Inc. • FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
®®�� +A '� 16.R� R•:TECASING.OR�.Tl7BING:(ge'utlie'r"malclo9ed:lonP)".:a � =- ---- ••-
2.Well Construction Permit#: V V FROM TO DIAMETER •THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C County,State,Variance,etc.) 41 ft /b i/ft. 1j,J-s- m. . 1b17 r'y f 0,
3.Well Use(check well use): ft ft in.
4y
Water Supply Well: s"517.';SEI ?' _- -
PP Y FROM TO Dr►naF^rxR SLOTSDTE TSICIUVESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft in.
c ❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
fl ❑IndustriallCommercial ❑Residential Water Supply(shared) 18 mom, -- - -
•® Obligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
k s Non-Water Supply Well: ® ft. ? ft. Boo odits
6 e"
I*�/ ❑Monitoring ❑Recovery 3' it. /of" ft �{ m yfr v,re puivedJC
®^ Injection Well: ft ft.
L_) ❑Aquifer Recharge .❑GroundwaterRemediation
1'19.SAND/GRAVEL PACK(if applicable):- -------_. -•
Yl�i) ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑Stormwater Drainage ft ft , k,..r ii...i % K7 :�
'
`V ❑Experimental Technology ❑Subsidence Control ft. ft. . n /w n
OGeothermal(Closed Loop)• ❑Tracer all'DRIfTiE1GIOG'(atfacli':s"dditiorialslieets:ifneceis`aty);�n r D 1--t1_`CU2_'4J_
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,salt rock type,grain size eta)
17 'ft Al ft i®i I. itlti:: :::'^;1 P,-7-:....;:•::;n l,'
Date Well Started 3 S= 7� /� (� �j y Ned
L -- :
Well(s)Completed: /—i! �r l [ �yt ft �r/' ft !7A/d t�+�c�if�` ,'.`r< � -
4.Date Tglr"If Well DO 7
Sa.Well Location: Phone#: 5k-21 t-.1 V tuft ' ft- le ft ��j�,"�
ri-c�lr ate[ tkilf
co ft. Jd�$'•ft. / i'e d,rei�ret aY
Facility/OwnorNa(m'eQ Facility (ifapplicable) r a OD- / it RdCk iv
vise 4
�a �9/`0/l � itA 4/l°r'��C° j �Se ft �,t ft M, 44 , � �'t•ve_
ft.
Physical Address,City,and Zip
County Parcel Identification No.(PIN) Cad +✓fit ►-vt
( ►'Y1�I aelke `1:4 e pe C.i rJ+ e.t' Cl-n i-,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
�eeA-;. 33cJ6-6-,1-i- 7 0 !';
(if well field,one lat/long is sufficient) 22.Certification:
pp Al till'
S,to of C(.. ed Well Contractor Date
6.Is(are)the well(s): permanent or OTemporary
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l`JNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stoisdards and that a copy
If this is a repair,fill out known well construction information and explain the nature.of the of this record has been provided to the well owner. G--
repair under#21 remarla section or on the back of this form. CD
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info �1
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: P 0 . (ft.) Submit this GW-1 within 30 days of well completion per the following:
For muliipie wells list all depths if different(example-3Q200'and 2Q100) t 0 n
' 24a. For All Wells: Original form to Division of Water Resources (DWR), !�
10.Static water level below top of casing: �d (B•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
yy 24b.For Injection Wells:Copy.to DWR,Underground Injection Control(IUC) it
11.Borehole diameter: (in.)Blt Off: lf!. 3r •Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: -C Kca In 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 countywhere installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA '
4/ Permit Program,1611 MSC,Raleigh,NC 27699-1611 p °
13a.Yield(gpm) t® Method of test: le �'�t 9 die ,
Date Site Visited: $r-20 w 2-5
13b.Disinfection type: 70% hth Amount: 3 el Oz Site Visited By: ryprg, 9 bill P'"'�✓ r`''
/rev AC Ida rA,La. I c ° °a' t,,,
Form GVr mental Quality-Division of Water Resources Revi
=n sed¢-6-2018
Price:_ FLEA Cri6fy Iva ...0
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