GW1--02323_Well Construction - GW1_20240410

` .,,I,CONSTRUCTION RECORD(GW-11 For Internal Use Only:
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1.Well Contractor Information:(I • I e
"D-�• d d A L)i A®� ipd 1 e ):-.' FiiWtTNtZONS'1"' 3 irt 3P>r: a i. ``i ,17,1.,::i:? `i+=Well Contractor Named sFROMp� TO DESCRIPTION
ti SC L - tl oft.` ft 4 9J
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NC Well Contractor Cettification Number 515 OUTER'CASING'(foraiiiilfi�cesed: 1)'.t)R'1aI1dER.'(ifip'licalile)�'" .,:i:
Yadkin Well Company, Inc. FROM TO DIAM�ETi I THICKNESS MATERIAL
Company Name + / ft 6 ft. (Y ia. ("fl 4 1 Ut
mP y �7lJ JIL ll J —
p� MIg i16:INNElt CASING:OR,TDBING iiitlieefmiire16 611;16 p) _._. �:."
2.Well Construction Permit#: eft t L 2.0 2- y- 0 o/6 i FROM TO . DIAMETER , THICKNESS MATERIAL _
List all applicable well construction permits(I.e.UIC,Comfy,State,Variance,etc) ft. ft. in.
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3.Well Use(check well use): ft. ft in,
Well: ?5:"- :. T _ ._ :...AM=_- _`.. --- _. --
Water Supply FROM TO ,, DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�M�unicipal/Public ft. ft .in. 151
OGeothernial(Heating/Cooling Supply) r _esidential Water Supply(single) ft ft in. IC
❑Industrial/Commercial ❑Residential Water Supply(shared) -48.:GROUTE-_"""`'—"_._,.____--,__.._--_,___ _.._--___.._.,�
❑lnigation ❑Wells>100,000 GPD'' FROM TO � ATERLIL EMPLACEMENTMETHOD&AMouNT-
Non-Water Supply Well: ® ft. Z•`ti ftg` it lffi l4t $#°!411,-P / 6 S
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❑Monitoring DRecovery ft ft r
Injection Well: ft. ft. -
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❑Aquifer Recharge ,❑Groundwater Remediation -
ir192"SA'ND/GRAVYZUTACK•(if'upplica)ile) ;!=_T_: z;:__.: .7 _'_ 2u . .
oAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft ! '.
❑Experimental Technology DSubsidence Control ft. ft .
❑Geothermal(Closed Loop) ❑Tracer r•20 DRIU7:lIVGI;OG'(iittarh ditlonalrsheetiiif;necessary)'7-________7_`=17
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❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO. DESCRIPTION(color,hardness,soWrerk type grain sue etc.)
Date Well Started '3, i 3 T"'� ,d� ft ! C1 ft, A e�'..4..v.v- ,. .
4.Date Well(s)Completed: .-13'�Z.14 Well 1D#A ''g a( 2.,# it. 6 J ft Oo i ..'(.It,;r• j spy 5 a. �
Phone'#:70V-') :T (9 ft, ' E it ',le lt�' ,
5a.Well Location: / 7 "° �, n � 0'a��l
Faaciliity/Ownerll/ h
ame Facility ID,_ l#(_iff applicable) I d f i ft A•yft 'r y (l p ��
f�39 O/d /bCd N r � &3 [
s. A a�!'"A,We Li(
ft 'Z.ft �^,t ��OQJ� 4 k ' L ii s 9
Physical Address,City,and Zip °�4 ft. ft i D. nt;.
5, . �`�� Hzlyuutvrau �.._.__.. W ..^.�.. .::�_P �_, cu:
. County / Parcel Identification No.(PIN) - inf," Win.7),- - '
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. 5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: y �'' t j
` (if well field,one lit/long is sufficient) ,,' 22. _!tificati! o
® V. w f I �7
g, z�"� 1 N I , ��� ' cal a 9• .14
• 6.Is(are)thewell(s): manent or ❑Temporary S;:•,'i a Jr edWellC�ntractor ' /� ' Date . .
fgnsng Ls form,I hereby certify that the wells)was(were)constructed in accordance with
` 7.Is this a repair to an existing well: DYes or tk1V a '15A NCA 02C:0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
3.Far 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. "
drilled: / 24.SDBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: '17D 0 (ft) 0.
For multiple webs list alldepths if different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:•
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10.Static water level below tap of casing: "� (lam
{i 0�•� 24a. For All Wells: Original form to Division of Wafer Resources (DWR), • 0
(ft') Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617 _
If water level is above casing use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) •,p
11.Borehole diameter: (in.)Bit Off: m.� Program,1636 MSC,Raleigh,NO27699-1636
12.Well construction method: a 1 r '& M!y 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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: 4-�
70% hth Date Site Visited: /2d/Z1-23
13b.Disinfection type: Amount: u OZ Site Visited By: D IA I ' ;
Form GW-1
North CamlinaDen atment of Environmental QualityDivision of Water Resources Revised 6-6-2018 \_ Il
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