GW1--02304_Well Construction - GW1_20240410

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e,•WELI.,CONSTRUCTION RECORD(GW,1)
For Internal Use Only:
1.Well Contractor Information: ''..• '
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• . OPYY1 14"CIA1 If‘' --- - " newAntmortEs _.:•_,_L..-...__ ..-_-...-,_-_ _,,i ... L.:__ _:.-....-L.,.-::,........ ---:::C...,-;:',.",j
Well Contractor Name FROM _TO .•. DESCRIPTION , .. ,•-,
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NC Well Contractor Certification Number ' I_
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Yadkin Well Company, Inc. likailltgrisld:fielli)',ORLTNERlitiitillelibler--- -
,FRom TO .. __ D r l'A' ..._ -TEIDS.S .- MT?
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Company Name - 'A& " - "1 .:ORTUBIf•N
2.Well Construction Permit#: /46: r41-- Po :FROM TO •- _ DIAMETER. 'THICXNESS IWATERIAL
List all applicable well construction permits(i.e.UlCounry,State,Variance.etc.) ',"+1 .ft. 6°C ft ,C.,I 2_5 in.. 5 I tu .. ilv4
3.Well Use(check well use): ' , fc. ft. in. '
Water Supply Well: 1 -- ,"la,13: .'- :',....--_,-__±=11;-1,".2.2-2ii...2if.7--__-'- -.::.-, .--=_•::,_-_.:=._,;-_.;.:.-2, ''-
i.FROM TO, mamma- ,i SLOT SIZE TiuCKNEs MATERIAL_
[agricultural . ElMiminipa/fPublic in.
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Geothermal(Heating/Cooling Supply) !Residential Water Supply(single) 1 ft ft. n., . .
Olndnsttial/Commercial pResidential Water supply(slia.tedl '.',4817...GB:thiri,•,,,y-z;,.,,,,: -..,.,.,j. •,,_ ,---___......___ ____.„_ _ __ __
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Carigation ['Wells>100;000'GPD ,.FROM .ie, .__. . irArsami.-_. irony:Fix-4F OD&Ariaitit
Non-Water Supply Well: H 0 ft £0 ft 6,1:104. rjetfr,47- to l4/17
['Monitoring EIRetovery ft , ft.
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Injection Well: " ,. ft. ft.
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ElAquiferReeharge El atoundWater RernediatiOn _
:aquifer Storage and Recovery CISalini. ty Hairier
['Aquifer Test , OStirimiwater Drainage
-ir faiperimental Technology • EISOsidence,Control H ft., , ' ft.
eia'S EIGeothermal(Closed Loop)
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' ElTracer 1;.F..iatl.9:0SINtift.7GRAHTOWEHPA.::37(IfiviAiiiirrauLliMile 1=.7.1 KurpLA-_' .-2,171.1.7.:,. HODistri2__if:: . .
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U20:11-RithiGLO-GplittfielildditirshliffitnecessaiV)1:_==
FROM TO DESCEUPTION(nolot,Isardneta,saillinck type,grain size,etc.)
IDGioth .(Heating/Cooling Return) Eldther(explain under#21 Remarks)
C 'DeteliVellStarted' a •,24). a ty , . -6
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AAA/ '-q7_;
4.p41,7p.116)Completed. ,)4C-,IL:well ID#. - . . . • '
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So _!len_ft. cfrti._ PO&to_ .5704
Wllicicalion: •
hoiie#: 312 g,y-5ett.,.rogzifjeift. iii,o., ft. ciLvt4;; 1.40,J4s ecpyrri.44,. Solo... .._
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, . . 1(0 •f-t; COO--ft. IfTNA- frrt,•4- Slot -
ft. ft. '
Pacility/OwnerNsine •- Facility.113#(if applioable) 41/20 t101 cle:".. it,L.Oa- Ale:).: --
111!
11 cliC4' Aiet. Tiesomr tt ie4 „7:4lieg _ ft. ; ft
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O •''cilysienl. ddress,Citidiii3' •.. .-i 1: tJa atiew . ft. ; ft S 'lip!? 1 :1 ,
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--. 'UDI'llite::2.'Ir-:1.6-s 2ii:".'<-1
count.i .: ' • •,• Parcel Identification No.(PIN) • --
l'...> - 5b.Latitude and longitude in degrees/mbiute.4/seconds,or decimal degrees: - - - - -- _: _ ,. ..._,..,_.,•... _
' ' • (ifievell field,one 1st/long is sufficient) ?
22.Certification:
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...,• ' : -3‘ t 3514S Z N .81 '0Z-3 Y-77 141" ,
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Signature of C • ed Well ntractor
64s(are)the well(s): lalierminent or OTemporary
By signing this form Ihereby certify that the ivell(s),was(were)consttucted in accordance with Sr"
• , -'7.Is titis.a repair to an existing well: 176.s or Lille 1.5A ATCAC 02C.0100 or l5,14ICAC 02C.02S0 Wen ConstruCtion Standards and that a copy LTN
• Ifthis is a repair,fill out know well constructioninforinadan and escpkittrthe nature ofthe of this record lic.s bane pro*led to the well owner.
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repair under#21 remarks section or on the back of thliform
23.Site diagram or additional'well details: .W".-
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 neded. Indicate TOTAL NUMBER of wells (add'See()Vet'hi Remarks Box).You may also attach additional pages if necessity.
drilled: ' . / • , 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: :I,1 V) .- - _
(ft-) -4tibmit this,GW,4 within 30.days,of well completion per the following:
. • For multiple wells list all depths if dehrent(example-3P2ntlf.mut 20.1007
2.2_"ti „, .*24a. FOr Alt Wells: Original,font to'Division of Wafer ResOurCes (DWR.), 1
10.Static water level below top of casing: .
(ft.) Inforitation•Prodessing Unit,1617 MSC;Raleigh,NC 27699'4617
If water level is above casing use"+"
11.Borehole diameter: a 13r
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06.) t Off: /...7)-.) 24b.For Injecticin,'Wells:Copy toiDWR,Underground Injection Control(IUC).
Progran- ii 1636,MSC,Raleigh,NC27699-1636 , •
12.Well construction method: -. . - 24c.Fdr Water.Sniiphr.and OPen-Loop GeothetnialRettirn Wens.Copy to the 03
(i.e.auger,rotary,cable,direct push,etc.) ,,,.. , _ dothity,envirohnientalhealth department of the county where installed
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FOR WATER SUPPLY"WELLS ONLY: .' - • ......•
24d.For Water'Wells producing over 100,000 GPDt Copy to DWR,CCPCUA'''*.k...
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Method
of test: !__ tait Prograta,1611 MSC,Raleigh,NC 27699-1611
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Per
13a.Yield(gpm) V *5'
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70% hth Amount: a4,4 oz . bate,Site Visited: a"/ '73__ .
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13b.Disinfection type: ; Site Visite'd:By:_ • . . . . .,
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Form OW-i North Carolina Department of Environmental Quality-Division of Water 13:nsources Revistd,6-4-jOIE
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