GW1--04341_Well Construction - GW1_20240722

WELTS CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
S'o V �t' ( � ' �V-I11 ff FR wAZ $ZONES
FROM TO r
DESCR1PT0N
Well Contractor Name !L
%4�' l 0 Y+A ft. . S0 ft. M
ft. ft
NC Well Contractor Certification Number ;ai`OUTFR CASING(foimulti"eased weIIs :ORLTNER ifn licatile
Yadkin Well Company, Inc. FROM I TO DIAMETER THICKNESS MATERIAI
t t ft. I
Company NameUP
<16 1NNFB'GASING:OR:TQBING "e'otiieimal" used-10
2.Well Construction Permit#:ao 2,-z�' 0�{Z FROM TO ID)IAMET.ER THICIQiFs M L.s ATERIA
List all applicable well construction permits C.e.UIC,Coway,State, Yariance,etc) ft. ft in
3.Well Use(check well use): ft. ft in
Water Supply Well: FRo111 O DIAMETER SLOT SIZE THICKNESS MATERLOL'
❑Agricultural ❑Municipa]/Pubhc ft. ft in.
❑Geothermal(Heating/Cooling Supply) Q<esidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 19'GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. Z. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
1.19.SAND%G1ravEI�eaC1�rf•z licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft, ft
❑Geothermal(Closed Loop) ❑Tracer ZO:DRIL*SNGLOG ittich additioifil shiiti tf neces
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM xo nEscRreTloN color,hardness sol]/rock S rtin size,etc
Date Well Started - H 0 ft. ft.
`� +
4.Date Well(s)Completed:0 'Zd� y Well ID# )— I ft. s ft r -4
5a Well Location: Phone#: 33C' -/ 113 ft. V ft
"s
I/tit V G/1(i�C (r'r►��(�G milli�
Facility/Owner Name 4 /�{ Facility ID#(if applicable) ft ft , �ree H Fg1#1, /� 7t ` l c n ft ft
UC'C e u�
—�Physical Address,City,,and Zip c�10 ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(dwell field,one lat/long is sufficient) 22.Ce cation:
36, 2-YJr / N 9C)13� r3 � 2- W ,A-i
6.Is(are)the well(s): B'Permanent or ❑Temporary Signa f7.111hereby
ell Contractor Date
By signing th certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V11. 15A NCAC OIC.0100 or ISA NCAC 0:'C.0200 Well Construction Standards and tlutt a copy
If this is a repair,fill out brown well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair tender#21 remark section or on the back ofthisform.
23.Site diagram or additional well details:
8. You may use the back of this page to provide additional well construction info (44
c onstmction,on lyly I o For Geon or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).Y ou may also attach additional pages if necessary. F
GW-L is needed. Indicate TOTAL NUMBER of wells
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 610 (ft.)
For multiple wells list all depths ifdifferent(example-3Q200'and 2©100) Submit this GW-1 within 30 day3 of well completion per the following: �.
(�� L 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: `y-�'�''� 1 O (ft.) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"++" / \
11.Borehole diameter: L, (in.)BIt Off: 60�_ 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a r '�(w/'./ 24e.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
13a.Yield(gpm) Method of test:
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
�t r
° Date Site Visited: Z
13b.Disinfection type: 70/° hth Amount: OZ Site Visited By:
r—ciw-1 North Carolina Deparhnent of Environmental Quality-Division of Water Resources Revised 6-6-2018