GW1--05532_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: i
y Q ' 1
• i e(r� l,"310r`F'Ec t A3 wsi.4'i'Wi+i.T.ER��:OPiES"`S(=:'_'�:,'. i . _ . .. '::t:.:'• -
WellContractorNaemee FROM TO DESCRIPTION �
`��A� • ft s o ft 3&FOO i.
ft p4O ft J 6,�� C
NC Well Contractor Certification Number
k 1 °011MER G--�ASING(f6%multi="e"a`sed4ellir:OR ANEFOi ap 112161);e i :": ..
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name
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�1-6`�INNFZi:GASRdGbRelluliIL1TG:(geutliermal�rlo'sed<Inn�..•::t:�.;.-::..:...
2.Well Construction Permit#: r 0.6 a kJ FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.WC,Comrty,State;Variance,etc) +I ft L S. ft 6 f in. SDR a 1 /" tit
3.Well Use(check well use): ft ft . in.
Water Supply Well >J7.-'anti$:—•"•"...'" tee'-' 'ilia, F _ ;:>zI ...-er' -,,$-n a.-b. �.
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agdcultaral ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) Xesidential Water Supply(single) ft ft. in.
DIndushial/Commercial ❑Residential Water Supply(shared) x :,r. .,
_18..GA07lT ;w., 5'_-�ritirs}a'.z ..:ai. ;"tea:.rid i•-`ir4 aLi.
❑Irrigation ❑Wells>100,000GPD FROM TOY MATERIAL EMPLACEMENT METHOD
Non-Water Supply Well: 0 ft 3 ft 14olt Plus Po u Rat •3 66f
❑Monitoring DRecovery 3 ft 1Y ft tibia.6colit Pumprel 3 CBS
Injection Well: ft. ft �+
❑Aquifer Recharge •❑Groundwater Remediation la19..5AU TGmlaiNIV ( h C Y'' ;t'b4-,VL' p•T-Y r3r ,YFL . .
DAquifer Storage and Recovery ❑Salmi Barrier FROM TO MATERIAL EIIACEgENTMETHOD •
❑Aquifer Test ,❑Sto>mwater Drainage ft. ft.
❑Experimental Technology - ❑Subsidence Control ft. ft . .
0 Geothermal(Closed Loop) Tracer - • 20IDRIfr1PIIGLOG.(attachildditiunal."skeeisif.'nec"essary),;=> '%` u, .c.r..y 'ti"tt;
❑Geothermal(Heating/Cooling-Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,somracic tyre grain size,eta)
Date:Well.Started T124.1244. • - ^/,� .Q. . 0 f 60 ft —�l^,,,°
•u . 4.DateWell(s)Completed:1I31014( WeUlD#Ae LIC, .A i &O. ft •yo ft ,Gf�196� -
'` `•• 'Phone#:.3/2 JZ'3 J 37 ®o f<. �•. ft_ ' £r'o� gook-Si.Well Location: p k- -
S o 14,'' /= 95 ft 12.1.ft . Griultte •
Facility/Owner Name 9'. • Facility ID#(if applicableeI) ' ft ft .
PhysicalAddres's,City,and Zip ' . 69®® .e ft ft.
. V [
V T I : ;e� . r. ;RF.M`eilitS,..,. T.25:.-. t,a P.t'1,
County Parcel Id,,ti 1cationNo. . ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; • ' D.145,:��'''e''"^
(if well field one Iatllong is sufficient) 22.Certification: �:y
30 .3/ g26" ?] ? P i .��•,e W ..
6.Is(are)the welI(s): Permanent or ❑Temporary Signatu;of C ed ell Contractor Date i •,
•
By signing this form,Thereby comfy that the well(s)was(were)conducted in accordance with '
7.Is this a repair to an existing well: DYes or • I+Io ISANCAC 02C.0100 or ISA NCAC 02C.020D 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#21 remarks section or on the back of this form. ' 23.Site diagram or additional well detail:
--8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same - You may use the back of this page to provide additional well construction info ,
constnmction,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:. ,i.,,
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total wen depth below land surface (ft.) •
For multiple wells list all depths ifd(fferent(example-3Qa 200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following: '
'•4, ll 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1.0 C, (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.BorehoIe diameter: . 6 (in)Bit Off:f. F.1 Q l 24b.For Injection Wells:Copy to DWR,Underground Injection Control(11IC)
Program,1636 MSC,Raleigh,NC 27699-1636 f
12.Well construction method: Ai .f 1 1.3` Air 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 ���p,,,ppp
FOR WATER SUPPLY WELLS ONLY: • 24d.For.Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA a
Permit Program,1611 MSC,Raleigh,NC 27699-1611 _ I `�
13a.Yield(gpm) Method,of,test: Fri V el/f -�
U Date Site Visited: 6 -- 1/-- 2 41, 4
70% hth `''' .O oZ Site Visited
13b.Disinfection type: •Anionat By: .416{ e,
1 P
•
Form GW-1 North Carolina Deparhnent of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: - ,