GW1--02302_Well Construction - GW1_20240410

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
'FX WellCoContrac r Information: I
".d �,� Y I (i e P • � s��4`:'.WAONES: 'C.`:':.� '•.' :. . _.,, iz.
We1lContraetorNa�e FROM TO DESCRIPTI/O�N�, �q
4 5 6 6 - A 26 0 ft ft ]
f. ft )
NC Well Contractor Certification Number tarie • 0
;13:OUTER:CA.SING'(fe%:multicnsed�welL��`;O1Z7:�ER;(iLap"7ii�efv `?�'-:� ..:'
Yadkin Well Company, Inc. FROM TO n7AMETER' THICKNESS ] MA 0-
' / ft. 79 ft Q t z. in. SO f k-1,
Corn any Name
�.
.`
p� T6='INNE,R:GASING'ORS.'L7BRIG:'ra the i enlos'e3-18Wfi r=::c:i; .1 . .. _
� _. : •,l.
2.Well Construction Permit#: I C)1 el W DI
FROM TO . DIAMETER THICKNESS , MATEBIAL. -
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ,eft. ft hi.
Water Supply Well: �7::S,CItt ak• 6Zti717.1.'' iNtil al`i7.1zni.'• .•`._•;.....,.a�di�: .,_.. ....-ZI,-4'n'
PP ' FROM TO DIAMETER SLOT gm? THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) Idential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ,; ;< --r v _ -
•
ji'1.8°,(sROUTL•.7,i�:..-.. ._. '�':5.:.wNt+. •-4'•• 1`�_n.S��+.:-�^ _�.. - .
❑Irrigation ❑Wells>100,000GPD FROM TO r~MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (, ft' 21 ft' j=*tse.,,,l p t e;A>p0 5.96-r ,4 Li y.
OMonitoring - DRecovery ft. ft
Injection Well: -
ft. ft
❑Aquifer Recharge .❑Groundwater Remediation
Isxo sANn/GRmZJe c1e p1i le7's ..:2_,::.;:;. :r;:A ";::. .._.. .
❑Aquifer Storage and Recovery ❑SatinityBanier FROM TO MATERIAL EMPLACE ENTMETHOD
❑Aquifer Test ❑Stomiwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft. -
DGeothermal(Closed Loop) ❑Tracer 20rDRTtf.INCr•I:OG:(atfacti ddditionaI'alieete .iieFei `" "'"""''''•— .
❑Geotheffial(Heating/CoolingReturn) ❑Other(explainunder#21Remarks) FROM TO DESCRIPTION(color,Irardness,soillxor$type grain size etc) �i
Date Well Started r'! 0 p Ij "Z1 n _ • 0ft' SO ft $0 / '
4.Date Well(s)Completed: 0��r 12..'A i1Wel1ID# APO- ®9 4 51 it. 79 ft. Ot r ,c L. • °.
52.Well Location: L 6 P O e#:,3 i 2.,3/- 3/or go ft, 322 ft Sd.`4 �/'ani"It
- I a h -&a 4-c ke v • ft. ft
Facility/OwderName Facility ID#(if applicable) , ft ft .E 4.,, :�' _.i '1.;-,''''''i' '
j7I2 (pre€, anA - PlljeP .S /a e d. ft ft PR t� 2O2 ..fi..
Physical•Address,City,and Zip e�� ft
Q..;l d- v 32l ItatvYAtirYcc.:-,,,.";-.7.rst. r.:: .'. t._ ;;.;A ?
(f� ( ems : y �_ .:�.;.�._�-
County ParcelldentiificationNo.(PIN) °`" i' l�-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - •
(if well field,one Iat/long is sufficient) 22 tificatio':-a aS .
. 3G- 3P3[ •�" N 1f:>f'F� 9�4' " w 1W/
. - :,.i . . Nit - 022'1 2' 2,(k
6.Is(are)the well(s): termanent or ❑Temporary lure ofr' •ed Well Contractor Date
' / .:ysignin:aisform,I hereby certify that the well(s as(were)constructed in accordance with
existing 7.Is this a repair to an well: ❑Yes or FAO - 15A N •' 02C.0I00 or 15ANCAC 02C.0200 Well Constriction Standards and that a copy
' . - If this is a repair,fill out known well construction n formation 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 ofthisfonn.
23.Site diagram or additional well details: -
• - 8.For Geuprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info' ,..g.)
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. X
drilled: . ' I. 24.so it TALINSTRUCTIONS
9.Total well depth below land surface: (ft) Cil
Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths ifdtfferent(example-3©200'and 20100') ,
10.Static water level below to of casing: S 0 (ft. 24a. For All Wells: Original fomn to Division of Water Resources (DWR), �.
P ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'+' g
11.Borehole diameter: Co (in.)Bit Off: 0, 0 70 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 631
12.Well construction method: /r go o kry 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 .ft...,
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,.NC 27699-1611 o e,j
13a.Yield(gpm)
Metho d of test: �-l OG. 81 A4,1,4 a 1
70% hth Date Site Visited: Z- W 4 2Y
1
. 13b.Disinfection type: Amount: Oz Site Visited By: b5aI
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__EotmGW-1 —__ North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018