GW1--04387_Well Construction - GW1_20240723

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4 J4 +,LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
LAS
1 tS Ocii t `.`14:WATEg'ZONES ? .
FROM TO DESCRIPTION
WellContrlactorN/aTe • ft. 7�/J ft ,j�`(ryy /��/y / LI G {y�
q610 / , �� ft. • t ft �� C II/�`" ,
NC Well Contractor Certification Number
`;15."0IITER CtASDIG fall-iiltir"c sed:welli) ( P:ORLIlYEIti ifa 'liellile
( . ) .AL .�
Yadkin Well Company, Inc. FROM TO n TER cI+lvFss MATERIAL `�1
6 ft 125 ". S z/ P ('L
Company Name -- .----.-
2.
(16! CAS G:OR•.LUBI.G.keo'th•e nal closed=loop) :
Well Construction Permit#: 37 PROM zo DIAMETER TRICKNI S MATERIAL ®
List all applicable well construction pernrifs t.e.UIC,Comity,State, Variance,etc) ft, ft in-
List /
�ft. ` ft in.
3.Well Use(check well use): /
Water Supply Well: - lxcli EII.
FROM TO DIAMETER_SLOT SIZE THICKNESS TERIAL
❑Agricultural ❑Municipal/Public ft ft /min.. ( >
❑Geothermal(Heating/Cooling Supply) )(Residential ft ft. (((l Water Supply(single) J • . l/
❑IndustriallCommercial ❑Residential Water Supply(shared) ; 18<GRo11T
❑lrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 'di}V ft. /j eni.7
1 G ij_e f-i 1- / (vi,1,6c
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Rernediation
DAquifer Storage and Recovery ❑Salmi Barrier i19•SAND7GR9vJ 13EAi 'lesipplicabiej• :• ' - •
q tY FROM TO MATERIAL EMPLA METHOD
DAquifer Test ❑StorrnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
flGeotherinal(Closed Loop) ❑Tracer '120:DRJ illNGLOG(ittachSiaditioialsheetsifnecessary
❑Geothermal(Heating/C olina Return) ['Other(explain under#21 Remarks) FROM TO DESCRD?TION(color,hardness,son/rock type,grain size,etn)
Date Well Started 4-i LC/ /, /�j6 1/ ft. 1 Q ft -0 /
4.Date Well(s)Completed: `ZL1 Well ID#�I C ` 7 0 R'' ` 6 0 ft lust- �D W
Sa Well Location:
Phone#:[phone] 1 6 Q ft. 2Go ft Ivy' roc k
/1G►
AYE 'l���t D ft. ft. .... _.,. . .
Facility/Ownere A q�g 743At Pi Facility)D#(ifapplicabbleJ)��� �f ft. ft \,A L.
•
j jl / pkft. ft
I 'n' 6
J1� �����(f✓e ��dA(�!� ft. ft UL 2 c. Eft
Physical Address,City,and Zip
l l , i 3 3 G.-r 3 71,.:21 IBMART{S _ ,- -,; .n!es!ey6iR.'' t•I,n'i;
County Parcel Identification No.(PIN)
—
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6—
(if well field,one la(Ullong is sufficient) 4.F4(2 r 22.Certification:ic C7,
6 ),/I 16 °9 N I/ b / W / �1j /_61Zi/ u)
6.Ts are the �,p ermane ❑ e Signature of Certified We Contractor (Date 7
Is(are) 7r nt or T mporary
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: DYes or o 15A NCAC 02C.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 under 421 remart 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 G4)7-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: l/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,2`'[e2 (ft.)
For multiple wells list all depths ifdii different(example-3@200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:
75 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.BorehoIe diameter: (j (in,)Bjt off:6 ,o7St
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 G`
12.Well construction method: I4,Y►" 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
Li g Permit Program,1611 MSC,Raleigh,NC 27699-1611 SO
13a.Yield(gpm) Method of test: C;11` 1,e4 'T
p
70% hth Date Site Visited: 3--/p -� df
13b.Disinfection type: Amount: 6 OZ Site Visited By: U 13
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: