GW1--03581_Well Construction - GW1_20240613

---_W LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
So d y LJ i I i,U " ("►o II,' S� 4 Wing . Zi ro
Well Contractor Name FROM TO .•' DESCRIPTION
u S 6 6 - 170 f3 c f5p� "'
NC Well Contractor Certification Number 1 OUTER:d'il-.SING(foimuiitrea`Ted'wdli)C01:10TER,"(if$P-lira` of.?:::'
Yadkin Well Company, Inc. FROM TO _ DIAMETER THICKNESS MATERIAL
l ft in. ,
Company Name
,/�, 363INNER:CASING:OR UBIP.IG: 7eotJiermarcl°iiitT-d68p)"•. •
2.Well Construction Permit#: c 19 3 $4 9_, �f�� T�/ FROM TO . DJ THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,Cow*,State,Variance,etc) 4f.l f. ' ft b JI in. Sp2 21 Pic
3.Well Use(check well use): It ft in. ►�•
i 7iSQt - is l: ,.::. '._....:o' ::: ,..':r:.; : ,. . .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ..../ft. r ft. in.
❑Geothermal(Heating/Cooling Supply) OR5idential Water Supply(single) i' /ft in.
❑lndustrial/Commercial dential Water Supply(shared) (:18:`"GROUfi
❑lmgation ❑Wells>100,000 GPD FROM TO MATERIAL CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 4 ft 14KAIa'f L C1'11 p J e OW
DMonitoring ❑Recovery ft. ft
Injection Well:
ft. R
DAquifer Recharge ❑Groundwater Remediation
j'19.SAND/GR`ItV.EDX CappliCeile): ....
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft
❑Geothermal(Closed Loop) DTracer s 20.I&ttt lNGZOG(attiieh dditi'o`nal iheeti if necessary)
OGeothermal(Hestia ohp�o ❑Othcr(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solllrock type,grain size,etc.)
Date Well Starte -7 - (.1 �/�- /�/ O ft Q j f .�
4.Date Well(s)Completed 9-L U. Well ID# '� -_O_ ft 4 r4ark,.r +t
Phone#:, .'Yt $42 i S ft. SCE ft. f01C +- ram•►f�.
5a Well Location: ' t( ft. i(� ft 1C
jgcaste
Fac'' /Owne-Name Facility U3#(if appiiri hle) '70 L 7y ft e JC+h.JJ 5 4 f Li.,b1-` S
Il efie,al I 76 " 2; rf.. . p-tte+'." $ t yam.. v.
Physical Address,City,and Zip ft
;21�• �S ` r.w, , Y E�..i
Vol kI n JUN 1
County Parcel Jdrntification No.(PIN) 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �
(if well field,one lat/long is sufficient) s ertific lion: p � '1 Li //_4'3,1— N SO- 7�i el 2 W /� S..... 9 -Z U
/� -of,f•;.ed Well Contractor Date
6.Is(are)the well(s): fier'manent or OTemporary
signing isfans,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or '1tg0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeII 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. (y
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 yW--1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Boa).You may also attach additional pages if necessary. g .
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2.0 (ft.) Submit thiss GW-1 within 30 days of well completion per the following: l"'
For multiple wells list all depths if different(example-3( 200'and 2@100)
U (ft)['` ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: D Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ,
11.Borehole diameter: 4 (in,)Bit Off: 64 0/ 0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a. 1 t g v+G".d 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,1611 MSC,Raleigh,NC 27699-1611 ''
13a.Yield(gpm) 3 S Method of test: C I og✓t^f r;
o r Date Site Visited: 2-2C'2-9' n,J he-
13b.Disinfection type: 70�0 hth Amount: 7 OZ Site Visited By: aV
no a-A i-rock S i9.4,,r
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018