GW1--04324_Well Construction - GW1_20240722

• WEI L CONSTRUCTION RECORD (GW-1) —For Internal Use Only:
wjx. contractor information:
CI
FROM TO MZSCRIPTION
Wall—c;:�)�]!tor�Rmc ft.
- 11566 -/� — —iL 11 5 O tti 1 ()
NC well Contractor Certification Number yuTEg -
Yadkin Well Company, Inc. FROM I TO I DIAMXrKR I TMCHMM I �gATPUAL
Company Name + I I Uq 5 -16, 1 z 10 sm-111 'y c
JEINNEXGASING'031:,' ING:ffifd&eF6ir cGia46,611i):
2.Well Construction Permit#: P[Z W L 20 2 3 Q 9/0 FROM TO DLAMM?R
THICKNESS MATERIAL
List all applicable well construction permits r.e UIC,County,State, Pariancr,ere.) ft. ft in
3.Well Use(check well use): ft. ft in
Water Supply Well:
FROM TO DLkbiK= SLOT SIZE mciclass MAT
............I I = —— 71
DAgricultaral 014unicipal/Public ft. In.
OCTeathermal(Heating/Cooling Supply) Asidential Water Supply(single) ft ft. in.
01ndustrial/Commercial DResidential Water Supply(shared)
DIrrip.ation OWells>100,000 GPD FROM TO MATERILL EMPLACEMENT TAFTHOD&AMOLVT
Non-Water Supply Well: H 2 -2 ar C 1;
DMonitoring DRecovery ft. ft.
Injection Well: R. ft.
OAquifer Recharge DGroundwater Remediation
19.SANV/GRX'RJWPAiaC(ifWTHiAU)1
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERUL EMPLAUNnM MXTHOD
DAqaifer Test oStormwerteiDminage it. it
ElExperimmatal Technology 0 Subsidence Control fc. ft
DGeothermal(Closed Loop) OTracer ,20.D G LOG(attzeb addititinal sheets if nec&ttaiy):*':
FROM To ]ASCRIFTION(color,hitrilness,solVrock type[]Geothermal(Heating/ oliing .00ther(explain under#21 Remarks) ft ft.
Date Well Started- 0
4.Date Well(s)Completed.-66-11-11 Well W# AAa- tlq ft. -5 3 ft OL,
Phone#:3-%--110-2290 -5 1 ft. -7,2 ft.
Sit.Well Location: t o
% 4 A Aemb, C---+e r ft. 70% ft.
.7—
Faclity/Owner Name Facility ID#(if applicable)
(111 ft. ft
2-4-Y L UC,4 tl-y ft. ft.
I
Physical Address,City,and Zip a-ion 2 2824
S(4 K VV
County Parcel IdentifiLAtion No.(FIN) w4a#A .'=rri 1-40%c
,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees- v s-
I A
(if well field,one lathong is sufficient) 22. er cation:
-3L,il 3 t6 'A' N k0 6 9 1 W
6.1s(are)thewelt(s): permanent or OTemporary Si f 61tified Can Date
'Vo this for hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an e3dstiug well: 13Yes or 4Wo 15ANCA4CO2C I oo or IsA NCAC a2C.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 weH owner
rep
air tinder#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
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only I GW-I is needed. Indicate TOTAL NUMBER Of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface, z CIZ Submit this GW-1 within 30 days of well completion per the following:'
For-multiple wells list all depths zydifferent(example-3@200'and 2@100)
'Z 0 24a. For All Wells- Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1,617 MSC,Raleigh,NC 27699-1617
If water level is above casing use
11.Borehole diameter: (ln-)Bit Off: 24b.For Injection Wills:Copy to DWF,Underground Injection Control(IUC)
Program,
12.Well construction method: OL iProgram,163C M-Sj�l�cigb,NC 27699-1636
24c.For Water Suppl and Open-Loop Geothermal Return Wells:Copy to the
(Le auger,rotary,cable,direct push,etc.) county environmental acalth departinnat of the county where installed
FOR WATER SUPPLY WFJLS ONLY:
.24 d.Fc r Water d over 100 000 GPD: Copy to DWIt,CCPCUA
Permit�P"g'm: ;�Co—'Iu
13a.Yield(gp-) Method of test: Ch Cn.�,,,O,,V;�u2�u7u9u9u-,"6,�rl� Ras -FU
13b.Disinfection type-, 70% hth Amount: Oz Date Site Visited: 3- -2!t f S- IV-2 Y
Site Visited By:_ IOJ71
be,
Form GW-1 North Cw-olian Dcoartment of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price:.