GW1--03578_Well Construction - GW1_20240613

LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: V5.1
M r { T
Sad W 1 1 ?I,a . r t I /I•+ V 4.WATE$ZONES '.: QV-.
Well Contractor 14ame FROM TO DESCRIPTION
• ft ft 0 a^f.
/�9
-L O 5 S -A ft. ft IJ /1 Q
NC Well Contractor Certification Number 15:'OUTER CASING(fui m'iilti=cased welt)ORLSNER(if fip litiitble) 5
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
t I ft. y Li. ft. 6.125 in. sOR-21 P yc i-c
Company Name
�j e� /y{,. 'i16:11e1ERCASIN .T G:OROBING.(getitliermalcloeed4dbp) .MV
2.Well Construction Permit#: 0I9 a'7Q - .^`! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(te.UIC,Cowry,State,Variance,etc.) ft. ft in. CP
3.Well Use(check well use): ft. ft ill.
Water Supply Well: FROMd0110TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) do1Cesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18f GRour
❑luigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft la 6 ft ti 4e P>< 1 S
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation
119.SAND/GRAVEIiPACK(ifapplicaable)'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
DAquifer Test ❑Stormwater Drainage ft• ft
❑Experimental Technology ❑SnbsidericP Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRIUINGLOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,
❑Geothermal(Heating/C o,1..a ling Re ❑Other(explain under#21 Remarks) solllrock type,grain size,etc.)
tua
Date Well Started 5 y 1, d ft 3 6 ft. d I�'r -
4.Date Well(s)Completed: C" AA '2.1 Well 1D#AAC - 130 3 7 It. 41 ft g r "
Phone#:336.24eY• 8'2 Ol ti s ft. 4kc it ! rv-+ t 4.
5a.Well Location: G
tt e/'p/'4. ft. ft �/ 1 `C `V E Ll �6``,.
Facility//OvmerNamee l 't Facility
yID/#�(if
applicable) �/ 6-
ft. ft 1 ��' �J'
it T 7'g. C oup-/ � -- CTYA14.11.//(�.ILA, 'ac /atVR 't ft ft JUN 1 •' �"2•
Physical Address,City,and Zip NC a1'1O' ft ft
t 21iREMARKR (rtear'r► �a
Ki►,. D'f C,"GO
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.C•i d catio.•
.08'1�.42.t N-80.54'17511 W ' 0 . r.1. 05 - 21 -2 w
6.Is(are)the well(s): C3fI rmanent or ❑Temporary Signs of C d 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 lDlfo 15A NCAC 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 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:
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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. 01
drilled: I 24.SUBMITTAL INSTRUCTIONS ®`
9.Total well depth below land surface: `(40 9.(it.) 6 )
For multiple wells list all depths if different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following: _
n 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( J (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 SU
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: y (in.)B It Off: �j_d 1 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: GM'' kb }'a rn 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 4‘.
(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
(gpm) (`Z Method of test: ( r Permit Program,1611 MSC,Raleigh,NC 27699-1611 (eel sr
13a.Yield
70% hth //�'� Date Site Visited: 1-2 7�9.� no S�
13b.Disinfection type: Amount: 2 V GZ Site Visited By: n 321
F,m GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018