GW1--02341_Well Construction - GW1_20240410

l `SWELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: , '
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1.Well Contractor Information: �n�c yI .
/' p 1YO� , fir4WATFOZONRs 4.j i..i..:,YJ'.t`1•0L�C5:..;:;,--1-,- AJ.:c '?•-:i- ;.c.4.'
c� cidt FROM TO •DESCRIPTION - 1-, ••,,
Weff Contractor Nta e
•erg 5� ft. F 3 ft / 0. !gam
5 ®.)-A ft �j ft l 1 ', ! t',J�
NC Well Contractor Certification Number f��
:i15:0U'.1'EII GASING'(fo'niiiilli;ca d ia1B)DRL-INEIQif r-1f ati]e)`�:72_7S '`i
Yadkin Well Company,.lnc. FROM TO DIAMETER ' THICKNRSS j MATERIAL
ft. ft in.
Company Name 3 c-$ 3 87 !3is? ,CASING:01tR'QBING:'(geoffierinaleluse3=luop)4;i-7-r ==: Ir.:
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits O.e.Ella Couny,State,Variance,etc.) +I rt. I V f .if O' Jima-( r V ! cs
3.Well Use(check well use): a ft ft. ; in,
Water Supply Well: a:�.an:can.'.-=` -�-_ _".__`__"- -_,L= .
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMpicipallPublic ft, ft. in.
❑Geothermal(Pleating/Cooling Supply) ilitesidential Water Supply(single) ft ft in. 1
❑Industriai/Commercial ['Residential Water Supply(shared) ,:18 GROU i._.=._= :- I`�_,� _ ' -__ w
❑luigation ❑Wells>100,000 GPD FROM-". TO MATERIAL EMPLACEMENrMET HOD&AMOUNT
Non-Water Supply Well: 6 ft i'° ft (ki-e..4�' ysoy.��'
❑Monitorine • ❑Recov ft, " ft �" r
Injection Well: � �t�• � �'�'t��li>/,' flayed'�•mod /�E�ls'�
• ft ft
❑Aquifer Recharge •❑Groundwater Remediationa
i 19.SA Iilaa'AVF FACT{(if applicable):".._`:__��=�.__.__._- _
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMEISTMETHOD -
❑Aquifer Test . ❑Stormwater Drainage ft• ft. I
❑Experimental Technology OSubsidence Control ft ft •
['Geothermal(Closed Loop) ❑Tracer ISKIilt> iNGLAG'(attic&ar7ditional'sheetiirn-ecrrs`tir-R2=-_-_ ..
FROM TO DESCRIPTION(color,hardness,soil/roek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) f. "rt.
Date Well Started _ Q' ®® �® �(:0 • 7 Sol
•
4.Date Well(s)Completez -e'dl;4'ef ID#M 0 O 9 a t�' 7'ft. /' 1 ft ,r4, / k'�"yj 6:.�, - i� �1s
Sa.• Well Location:
Phone#:_53� 'R Y-OSC4 rcit`�ft 7 O-ft. gle.;,( ¢ � �
t �7�ctr7l Anstr4,44- 6„llda. - f ft ft e t Le C.. ►.`V i.:.
tyty/w. .H0 vie 15 334-972— 6Fs2�i - •
Facility/dd(wnnecrr Name Facility ID#(if applicable) • • ft ft. Q p D 1 (, VA'
11 1'4t k9 /`l 6. tlt0 A S�1a '..ft. ft
ft. ft 7n:-: l;'r, •Wera.•F Cl?
Physical Address,City,and Zip ,��t;„Q-1 : ' 'Infi;r -��,r,..9 •"
i.7.DREIVIARICB•:__..::::-_..�..7.:„.�:__. "-_"' -
°TVCounty Parcel Identification No.(PIN) _ 0
• fib.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: ---C)
(if well field,one Lot/long'is sufficient) 1 ( 22.Certification: •
. w - i''': . hid_i iiviSell‘
1 6.Is are the weIl s: �Yermanent or OTemporary Signs e'ofCerf ed ell Contractor Date
By signing this forzn,I hereby certtfy that the,well(s)was(were)constructed in accordance with' '
7.Is this a repair to an existing well: .❑Yes or Cho 1SANCAC(DC_pi 00 or 15.4 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 of this record has been provided to the well owner.
repair render#21 remark 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 GeoprobelDPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW�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: WO (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdf rent(crumple-3Q200'and 2@100)
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" g3�
11.Borehole diameter: 6 (in.)Biit Off: 5;VC 24b.For Injection Wells: Copy to DWR;Underground Injection Control(IUC)
Progtam,1636 MSC,Raleigh,NC 27699-1.636
•
12.Well construction method: d 6 r r_ershurip 24c.For Water Supply and Open-Loop Geothermal Retain 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
1/2,.. ° ° Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2 Method of test: If; o-i r ��s� g `s,cn�p
70% hth Date Site Visited:/4-2 -'�-3 tom'1S
13b.Disinfection type: Amount: 0 OZ Site Visited By: Ll a+
.;
Form C3W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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