GW1--04362_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j<7 L
..c IA) { c) w 4 FJ4:WATI+$'zONES].. >r;
FROM TO DESCRIPTION
Well Contractor
Name /
76 ft. /'7 p ft/o/)
NC Well Contractor Certification Number 7l15.�OILTIF C`AS 1NG(f6imu1,ti4=ased"vveIIs)':ORI.IIVES2"(if:np lieatilef,: CA
Yadkin Well Company, Inc. FROM TO DI: R THICK', MATE:LI ,r
-ft ft / in. �� ,�
Company Name J
! A ® `16 INNER;GASING:OR:luBING(Qe'otHesmal"'clo'sed=loop): .
2.Well Construction Permit#: li, FROM TO . DIAMETER THICKNESS MATERIAL ( ���,
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) + I ft. - er ft %J/ in. L*) %Kg , 6 /✓ dJ //,e.
1 ft. _J ft C� in.
3.Well Use(check well use):
Water Supply Well: Ps
FROM _TO D TER SLOT SIZE THICKNESS MATERIAL
El Agicultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) MACii.EieetittiNIWaiitezZipply(single) ft in. - /
['Industrial/Commercial .esidential Water Supply(shared)
❑ligation ['Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. /L. ., -
-e,,tr•L //
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft Cr-
/1/61,T ti f,/C
['Aquifer Recharge ❑Groundwater Remediation IJ
1'19.SAND%GRAYEI:YACK.(if;'applic iiIi) -
['Aquifer Storage and Recovery ❑:Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ti(p.7
❑Aquifer Test ❑Stormwater Drainage ft. ft / / /
❑Experimental Technology ['Subsidence Control �S/
['Geothermal(Closed Loop) ['Tracer ''20LDR1YSJNGI:OG(attichadditionalsheet!if lie cessary) :'
FROM TO DESCRIPTION(solar,hardness,soil/roek type,grain size,etc.)
['Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) c !
p
Date Well Started 6-/L-g'{ �y 0 /ir Qr
4.Date Well(s)Completed: H /ef-.Zit Well ID#/" 464 - 19 7 r Zft. 642- ft .s )4,-;,,i, / tii S/ved f0/ih.
5a.Well Location: Phone#:.. 36 - Itil-23s q s•2_ ft. it y.2 ft 6(6nlIto
/.vied".
,
n P «!f ft. ft. - ��
u /VAVfA (r0 Curiiin & JO - ,'- . ...if 1..r
Facility/Owner Name Facility lD#(if applicable) ft' ft'
C. k a?e LA Fik(riN gh. 1xMt( Elk!Isi' ft ft ;' it_ 2 20'` If-
Physical Address,City,and Zip i 609 ft. ft
�( It RF.MAVCC;:' '• .t .. S '.r:.. + '...y -'?'.' .N., '
W.. ..J` ion // ro
County Parcel Identification No.(PIN) 4 LW 6 /'1 1:4- r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: N
(if well field,one llat/long is sufficient) 22.Certification:
3 t' 17 1 N S I .t /S Li / W f' ��-► - t.6�- /y-4'
6.Is(are)the well(s):' ermanent or ['Temporarygnature of Certified 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 1p10 ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information a d 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 GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this pageto 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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: j (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2©100')
10.Static water level below top of casing: f ` 24a. Far All Wells: Original form to Division of Water Resources (DWR),
(f') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wafer level is above casing,use"+"
t' 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) G.'"11.Borehole diameter: (in.)Blt Off: Q Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A'r- it'ik` 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the ..O
(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) 3 / Permit Program,1611 MSC,Raleigh,NC 27699-1611
" ^r .//
Method of test:
o Date Site Visited: O Z 3C2X
13b.Disinfection type: 7O o hth Amount: 3
( OZ Site Visited By: J
(_,1 1riie.'/ j.., 3.-/l -Z.
Form GW-1 North Carolina Department of Envirorunental Quality-Division of Water Resources Revised 6-6-2018