GW1--04383_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 0
1.Well Contractor Information: _ ) �- F
c) Y L 11 I C- i 1 14 J r ! 14i WATF.I,t'ZO ESi to 'F S
Well Contractor Name �'+ FROM TO DESCRIPTION - 11
it ! 0 it (V J'
Li S' 6 -A ft ft
NC Well Contractor Certification Number `:1i.`OUTER;CASING(fo'z multi'caiedivveIlti:ORIIPIEE.11,0.lnp'licable).;
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
f i ft. 8 $ ft 6.i 2.s m. 59 -Li rt16, D
Company Name es a16 INNER.CASING'OR;1'IIl3ING_(geotliei•mal•closed=loop)' ....
2.Well Construction Permit#: G13 2C ® S 3 - a-ce;Z y. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in
Water Supply Well: FROM TO DIAMETER_SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) [33�esidential Water Supply(single) ft ft in.
❑lndustriallCommercial ❑Residential Water Supply(shared) 18?GHOUT:'." .'
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft L 3 ft pY� pBl ) pity- ckpf
❑Monitoring DRecovery ft. ft.
Injection Well: ft. ft
['Aquifer Recharge ❑Groundwater Remediation
if 19-SAND/GItA;YF :P.:41`IKr(if'61PP&ealt`Te)r • • • .-
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ['Subsidence Control ft. ft
['Geothermal(Closed Loop) ❑Tracer 20:DRILLINGI OG Sattneh iatlitlEilarslieeti if ne/iai iy)': '_ ."; ;..;.i:.' '
❑Geothermal(Heating/ o1� Re ) ❑Other(explain under#21 Remarks) FROM TO DxscaleTloN eolo,hardness,soivroctc type,grate size,etc.)
Date Well Started 6--( L 1 U Ate ' 0 � - ft. 0 r.0"
( r' ]_
4.Date Well(s)Completed:6-7�-2 1 Well ID# -- 160 2 ( ft. 7°J ft. pl L; J J
5a.Well Location: Phone#: f x y�2- �9 7 i ft. u ft el�,.-,l'i„c
I " ' 2-0 ft. �rt'Vll 4-t , 1.. L,�;
C
ft JUL 2 , 2024
Facility/Owner Name �� y� Facility ID#(if applicable) r1
1 7/L ga�v�..s.f rt .f P. chv%I e, ➢V� ft. ft _ C
Physical Address,City,and Zip f�Ot 1 ft. ft - ,
ii-(�7 �1✓1 V :2114FM.ARICR.. LrP't ;.,"ye•"u
County Parcel Identification No.(PIN)
CI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. er cation:
X. igr, .
22 te(,� ' N W4,, 6 2 7�-C)" WAizia 6 . 12 -2 11
6.Is(are)the well(s): Ri rmanent or ❑Temporary Sign hie ofCertifie ell Contractor Date
_� By signing this fo n,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CENo I SA NCAC 02 .0100 or ISA NCAC 0.2C.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 tinder#2I 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.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 0 (ft.)
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:
G (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below tap of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)Bit Off: 6 .C' 4 6 fib.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 041/ r rfIy 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 tl
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA -Is
r Permit Program,1611 MSC,Raleigh,NC 27699-1611 L
13a.Yield(gpm) J Method of test: f aK`
n Date Site Visited: III-1f'2 y
13b.Disinfection type: 70�o hth Amount: OZ Site Visited By: b,'4 5e. a--r+1 pQ/A.s 4
-CN
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018