GW1--05536_Well Construction - GW1_20240913

-WELL CONSTRUCTION RECORD(GW-I
Z For Internal Use Only:
1.Well Contractor Information:
Is
..her . LA3a4' g.7.,4.WAT.Ek2`•ZOPIFS`'r C^::i'•:.•.',.r},' . ..'s•• , ., ,
Well Contractor Name FROM TO ..• DESCRIPTION ageZA
fti ft i ; 't
NC Well Contractor Certification Number
:1vouTERag.1NG"(fOKailfi`;cased'we114:01 ERi(if ap licaUl0.71, --• '
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNII7ss MATERIAL i
Company Name ft. ft in. >♦
7.
s tiT6SINNKIZ;GASINGORSI BING:(geotlydi:maTrlcialniiir,:'::?;:Si ,.:i:e;..:,.
2.Well Construction Permit#: 30 /„fib 330 0 CRNi+
PROM TO . DIAMETER THIss MATERIAL.List all applicable well construction permits(i.e.UIC,Coun4,,State,Parlance,etc) cl.i,1 ft 14 ft / `,�,® in. a 188 / .I l .
3,Well Use(check well use): ft. ft (O 6 in (�
Water Supply Well:
rOZ.5'CR 0"r.....'a:+ ... ;':,.. .....•:,:: _:_. .:._-._"`Ax- .— to,i
FROM .; �' :...,
TO R :DIAMEraa SLOT SIZE R THICKNESS MATERIAL
ElAgricultuxal ❑MunicipaUPublfd.l ft ft. in.
OGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
OIndustrial/Commercial
identa l Water Supply(shared) ;
+ :i.:;'�.•..�i.:s
ry18,GRObT....-.,',..:r..i., i.il:r • vr:.k. .:':?:';%`�l�`:�...T ::�.:,:;r• Ii'
Olrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 3 ft Note Pi P�r�t bi (©
;r]Monitorin
g ❑Recovery ft t
Injection Well: �� f Qvwlc Grob �wt
ft. ft
DAquifer Recharge DGrotindwater Remediation '
❑Aquifer Storage and Recovery ❑Salinity Barrier I1J SAND/Q�A'Q•EIkkP'AGI- )ic1b e i ''' ,:,,;-7.-:-1:1a-�;��;-°.t-.:-,,: -:_`
FROM TO MATERIAL EMPLACEMEr TMETHOD4.'
❑Aquifer Test ❑Stormwater Drainage ft. ; ft ,
DExperimental Technology ❑Subsidence Control ft. ft
`❑Geothermal(Closed Loop) °
[]Tiacei `20 DIULTAl+iGrOG'(attachii0ditiuif;I`slieitiiiii cess
lOGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Date Well Started 'lgf24. �� p� 0 1 ? ft 0;;)
4.Date Well(s)Completed:8 p 1, I7Li Well 1D# 1 1:`4® n" -1 , G,s3 ft gal ft /y ra fp 1 kr
Sa WeIlLocatiott: 1 - , Phone#: 8A a ;v�)aa(aai% ft. ft •
:D6"��!%t I KO iY't t ' es: ft. ft r i; f
Facility/OwnerName � . Facility ID#(if applicable) ft ft Le
r
�_ 9 R ft SE P 1 2024
a � ,� , �
Physical Address,City,and Zip ft.
ft lrl`v T:1Z: t"il Pr':nr
..i4 v I lsr
•
213 RlMARCC;`;ii .... 3' _. r',ar .:_. E'ut Cat .v,.:>-�-.ak..rq
:l ' A0k. S� .
;County j
Pastel Identification No.(PIN)
-5b.Latitude and Iongitude in degrees/minutes/seconds or derirn2l degrees: Cm
(if well field,one lat/long is sufficient) y `y 22.Certification: 04
00
6.Is(are)the well(s): °ermanent or ❑Temporary sigpa a of C ed ell 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 , To • 1SANCAC 02C.0100 or ISA NCdC 02C.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 hat been provided io 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,piovide additional well construction info
construction,only 1 GW-1;s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
s 9-Total well depth below land surface: e0.1 ft
Far multiple wells list all depths y-df#erent(example-3®200'and 2Q1005 ( ) Submit this GW-1 within 30 days of well completion per the followings
{ 10.Static water level below top of casing: ISO ft 24a. For All Wells: Original form'to Division of Water Resources (DWR),
Ifwate�level is above casing,use"+" • ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.BorehoIe diameter: (in,)Bit Off: lj. 1 1 24b.For Injection*Wells:Copy to DWR,Underground Injection Control(IUC)
q Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ev1 1 t (o+&'l y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed Py
- FOR WATER SUPPLY'WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPI): Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 -0
13a.Yield(gpm) Method of test: b At l kr l o'
70% hth cUJ Date Site Visited: 3 ® I 19 ,7 L
. 13b.Disinfection type: Amount ® OZ Site Visited By: Pi 6 "F-
Form OW-I i p N rth Carolina Department of Environeiental Quality-Division of Water Resources Revised 6-6-2018
Price: I A LAkStEta �aa aw °�4�I l2 w. _. w �s_ • -- - A