GW1--05482_Well Construction - GW1_20240912

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: WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I -
4-&A (_&-Vt `'S 4i.WiilEkZrZONES%: ; i i. r.. 1
•WellConnactorName FROM TO DESCRIPTION "''S
r ft. ft CA
NC Well Contractor Certification Number '15.`POUTER:CASTNG',(foi:`mulg°cased weig`:OR aNElt(ifa"licalil'ef+;; .:•. . N..
Yadkin Well Company, Inc,, ~.FROM ' TO DIAMETER THICKNESS MATERIAL
ft. ft. in. 0 D
Company Name a 61I NF.R:CA.SING:ORiT17BING pVtI etmal doaea tiMt.: J.;a:;;",L-:'.,•_.
2.Well Construction Permit#: FROM N. TO . DIAMETER THICKNESS MATERIAL
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List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft in.
2/
3.Well Use(check well use): ft ft in. ^
F_17'yS'.. .'.':";ir:.,:rs...'`'i�, c 1' i.`"7:4'::•'r.:,.' �`.`1 'ED�. ___. �3 . .
Water Supply Well: FROM TO 'DUAMETER ,SLOT SI y THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft In.
. ❑Geothermal(Seating/Cooling Supply) XLesidential Water Supply(single) ft ft "Ilk
❑Industriai/Commercial ❑Residential Water Supply(shared) .ARV: it :._;•..,;. ,7:.:7.‘"'• .•::-::;S:_1'r•,T.;. ':,;i""
❑I:-igation ❑Wells>100,000 GPD FROM TO .M ItJIRLtL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. d
• ❑Monitoring DRecovery ft
Injection Well: ft. ft.
❑Aquifer Recharge DGroundwater Remediation
1 19'sAND%ea•:," Y CMif.5pp aier :: a aN;:;1. 1-a'1::;::``'v:d..` .
❑Aquifer Storage and Recovery ❑Salinity Baaier FROM TO MATERIAL EMPLACEMENT METHOD ' •
DAquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control • - N.ft.. ft
DGeothennal(Closed Loop) DTracer 20iDRIY,T TGTOG(attulfIdattiurial"sheetiif'decensii;i* .;7a.:Sr2fi.. •
❑Geothermal(Heating/Coolin°Retum) ❑Other(explain Mader Remarks) FROM TO DESCRIPTION(color,hardness,soillrackLyle,grain size,etc.)
Date Well Started -at-pi J )ft. 16o•-ft ril t c4- 9/a.7 5,D4 t c "'
4.Date Well(s)Completed: Well ID# 1�/ UL' . U ft. ft •
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Phone#:7 7-4 2-'zit) ft. ft - -� { .
• 5a.Well Location: ±1 f _-* '-i
,I / ft. ft. `^.,- ‘..„.•C.-. � ��LI
;ri, "14 a�.(5©#7
Facility/Own Name Facility ID#(if applicable) ft ft' S E P 1 2 2 ?4 - 1
-81.0 2 Af)G&� ka 4 ,t e e 6y ft. ft I -1
��pp r..
• /� ���`f� ft ft •rtti::� tS,Txr
Physical Address,City,and Zip D- C:,:41 i;r.',
County Parcel Identification No.(PIN) `D'e•1.1f� al' .Si-e'b l - 's00
�d��� u �jc
Sb.Latitude and Iongitnde in degrees/minutes/seconds or decimal degrees: 9Ar.S -c t ( C�St
(if well field,/one Wong is sufficient) �i _ 22.Certification: f:' c:;;1. 1
. •
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N
6.Is(are)the well(s): Permanent or DTemporary
Signature of Certified Well Contractor Date r
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
•7.Is this a repair to an existing well: DYes or dNo • /5A NC/1C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out)mown well construction information and 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 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. '- i 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 0. (ft.) Submit this GW-1 within 30 days of well completion per the following: ^�,
For multiple wells list all depths if different(example-3Q200'and 2©100) Cr
24a. For All Wells: Original form to Division of Water Resources (DWR)r.
10.Static water IeveI below top of casing: (ft.) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617 SU
If water level is above casing,use"+" /' Q�) �-
11.Borehole diameter: `o (in,)Bit Off: �; S C/ 24b.For Iniection'Wells:Copy to DWR,Underground Injection Control(ItIC) • .
Program,1636MSC,Raleigh,NC27699-1636
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12.Well construction method: Cs l ' rcT+ikP 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
1/13v Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: t's f s 6-1 pi�
oDate Site Visited: '7-- /�g- , ?
. 13b.Disinfection type: 7O�o hth Amount: OZ Site Visited By: A 6 l
J`. I+.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: j