GW1--02307_Well Construction - GW1_20240410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
•
1.W ontractor Information: '
VGtw1 ej l%1C6.L( G'iac,WATE13'-7ANES 1_z . ; n1,a"S':1 :. ,.,i-=,';l •,l• .;y.: ,31 ...1"(a- »:�:.t W,
Well actor Name • ]]rF�ROM TO DESCRIPTION D {�
1Ia t�01 Tt' '1 2(�S fit ,S`hsi,,; (C - 1 0S$! CA
CA
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NC Well Contractor Certification Number ;15:0IITER'Crf:SING-(foNmuligasedWells)°OR'LINF,I far"ticalile) = ,:i,':'
Yadkin Well Company, Inc. FROM T DIAME Tffi MA7 6/9
�ft. fit / in.
Company Name 111 f e`ti v� ';``
e'�1 r� `i16.INNER:CASING.ORTUBING:(Re`ritlfer'malclosed=Ibop) Ill - L �.3
2.Well Construction Permit#: ' 2 1 ( 0,I. :- FROM To DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits e.U_TC County,State,Variance,etc.) ' ft. '9 9 ft 6.1,i1 Sin 1 V C.21 10/ -/_ M.
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3.Well Use(check well use): ft J ft G in.
'17:1S7d "M_-r,�_;` ,"------ -w-. - `-" ` =�----'3
Water Supply Well: FROMt TO DIAMETTIi[SLOTS S MATR Tq4
❑Agricultural ❑Municipal/Public ft. LA
❑Geothermal(Heating/Cooling Supply) jesidential Water Supply(single) (/
fit it in.
❑Indushiai/Commercial ❑Residential Water Supply(shared) ,- ,, ----__-_— --.__ ,,.____--_...__-.__
is:.GRov7c w;�
• ❑Irrigation ❑Wells>100,000 GPD FROM TOe� . 6.ATERa^ y tEMPLACEl1�+Nf METHOD&AMOIINT
. Non-Water Supply Well: 0 ft A o ft . /'14I iS9v1y .J f I_G . 7
❑Monitoring • - ❑Recovery ft fty V 7 t
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation ____«___ �_- .0
u19:`S'ANDIGRA LPACK-(if.applicalile)�:_:ice, -` _L:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO - MATE $L EMMA METHOD CM
aa ❑Aquifer Test .❑StormwaterDrainage f<• (
ft `J
1t ❑Expenmental Technology ❑Subsidence Control ft. ft ( E
0 Geothermal(Closed Loop) ❑Tracer i_20 DRI INGEOG"attacli`¢dditii al'sheeti if.necess
FROM Ti , DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
o CI Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)• P
C Date Well Started 3-13,,.0 ® 0 ft l ft S o' j a
M . 4.Date Well(s)Completed:1-r A ad f wauco#4 O.v 3(4 ($ ft. g 2U ft ya`4- Soil-
Sa Well Location: Phone i� 1 o�, � / ft lla ft I115hd' pl.-, !?/G�- {'1Gd'a cl, i.
l wk. hemil' • .. - 1it64 lei (witty �ao°V1'os I°.�1 U,';.( fsk:(L,l.7 ft. 161.0 • ft flak late__ �1pYa ti I
Facility/OwnerName . Facility 1D#(if applicable) Oa el ft .136.
j�.. fit 1 ,
5 /..1): a• t4f�Aad��4 1�oc,1+ �1 r:1l V /'4.31pljep-S� ,.3d� 1 ft. tLo ft t is2ld- 5pi, wiirK L___J ._. .
- Physical Address,City,an&Z_ip ���. ft. fit Y /� ��' -
. • P.i. ii4,tin ei,„ ' i 2I RuMeLRucS.: R;_;.:2;:-n-a=12 - x—_. - �- --- f 5
County ParcelldentificationNo.(PIN) �'u^"'�"r i....2¢ 1! •" . _
.. • . i7 '
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •A P i I 0 20 2/1
(if well field,one lat/long is sufficient) 22.Certification: -
L `3 I' ,y .�'
` .I® N g ) ® Li9 1- 3 L+ e/ w ' --------' n Unii , ,
n,,;crjM ;, �r.R e.g. ,,'
,.,dam, =?� e
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6.Is(are)the well(s):'ermanent or ❑Temporary, Signature of Certified Well Contractor Date
By signing this form,I hereby certify"that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or XIo 15A NCIC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy �.
If this is a repair,fill out known well construction Information and explain the nature of the ofthis record has been provided to the well owner. 5
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:•
You may use the back of this page to provide additional well construction info
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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �` 3 Z Submit this GW-1 within 30 days of well completion per the following:
if
For multiple wells list all depths different(exampla=3Q200'and 2®100) c
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: - - eiUrJ 77 ,3 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" •
11.Borehole diameter: �� (In•)Alt Off: /' 2 24b.For Injection Wells:Copy to DWR,Underground Injection Control.(IUC)
(✓ Pmgram,1636 MSC,Raleigh,NC 27699-1636 -
12.Well construction method: 4, r t^O' / 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: r-
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m • • Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) -C Method of test: h A. A(
70% hth Date Site Visited: � •� <(r i''
, 13b.Disinfection type: Amount: OZ Site Visited By: ,,�,a
1 '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: V-.?a . e(,,,,1--' C