GW1--05537_Well Construction - GW1_20240913

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..- WE+LI, CONSTRUCTION RECORD (GW-11 For Internal Use Only: 1
......"---°5-f Well Contractor Information: 9 ,I •
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Well Contractor Name FROM •' TO DESCRIPTION'
?�' .i A - ft ft
NC Well Contractor Certification Number T Q g �`$��y ft (9 �y1 i S� Al
615 OUTER:CA.SING"(ftir"multi~,edsedweiliI..ORIs7PTEIt{ifap liaL1kr..=a.=...,,ivy:?..
Yadkin Well Company, Inc. • 'rl,r': FROM , TO DIAMETER -THIt THICKNESS MATERIAL
Company Name :. ft. fL - fin.
- 1165INNEECCASING:ORTUBING(geutliei `' *rO.T.•�""`•=+= a
(J� "� c FROM .TO DL-MHTER THICKNESS MATERIAL
2.Well Construction Permit#: - ..� ./��.r--s ' _ r _
List all applicable well construction perntita;(.e:.f11C,'.County State,Variance,etc) a;�-! ft. IC it I in. 188 6.1
3.Well Use(check well use): ft. . ft I! in.
"Z.'/g.%li l�.t_ .�iC' <«dewti3? `: r a aa"'"3,3,`"i'1'",._2.1';"r`''''T''`c am'iii" :.:;47,:'
Water Supply Well: =
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ umcipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ` estdential Water Supply(single) ft ft in;i
❑In dusty i al/Commercial ,❑Residential Water Supply(shared) ;18�GROU1'ea:Atn7g '=��'q t ..,U'S . ..'°`"t�;:�.,2n?:'?�•:':.=sag w."1«:,i2
„••:_5-"* FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Irrigation ❑Wells>100,000 GPD
Non-Water Supply Well' 0 ft .�/"3ft I4ok PI.3 Pove.J i3 tgo.$
❑Monitoring ❑Recovery ft. \ ft.
Injection Well :•. ft. ft •
❑Aquifer Recharge - - _ ❑GroundwaterRemediation !•
i119_SAND/GRAVELPACK"(ifapplicable)" " -5; ,i I-: ^.`?� ',:3IIV.'t .
• ❑Agnifer Stomp and+Recovery •OSalialtyBarrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test, ❑Stormwater Drainage . ft, ft. I.
❑Expenmental Technology DSubsidence Control ft. ft '
❑Geothermal'(Closed,Loop), `-,OTracer.•. � Pr20!DRI1 I1IGI OG(atfa`ch addition`a�lshee'teifnece sary), �i�o ;a"::::tf`"?";
4 ❑Geotbermal'(Heating/Cooling Return)_„'-. DOther(explain under.#21 Remarks) FROM ft TO ft. DESCRIPTION(color,hardness,sotUroek type,grain size,etc.)
•
Date Well Started, ►13' a •- , 9y 5t�210
4 Date Well(s)Completed: 1 �% Well ID#�! ', 9w 14)3 4 C4, f t`P
F -Phone it. ('" ^ _ •.,/ ft. ft.
Sa:Well Location: -
"A Facility/OwnerName Facility ID*(if applicable) f ft• 1' 0" ^k... ., err4".,;'"`'
gY Physical Address City,and•Zrp ':_.' ifc ago in ft ft ! 1 Y. e u 2 4
' ::;. t A`�1 ,- -, e� d .RF:m RKC ilizr,`'t.r,,Ntr2':n....:''.�Nr`.i - rt':�._.?ect, 'B: r�."z . •es,4,;:'
14 -6.4 q, coo - "
County` ParcelIdeatificationNo.(PIN) t'*e /I��& it �� •o' Ut, .
Sb.Latitude and longitude in degiees/agnutes/seconds'or decimal degrees: . ,.,
(if viell Feld,one iat/loogis:su&cient) - - - - i'
',.22.Certification:
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e _./_�`=_4 94' N. '/ -_ le ' ..3 a w .,
)Mta ' 147 ioLi
- :6.:Is(are),the well(s):,• ermanent ,or..`OTemporaiy_.'. Signature of Ce • ecl We 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 fro ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if thiEjs a repair,fill outkaown well eonstrtretiott information-and explain the nature of the of this record has been provided to the we'll owner.
repair,under.il?I'remarlasectionmron the backofthisfcrm.,�'' • '
r - 23.Site diagram or additional wen details:
8 For Geopiobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info -
t..-,-:•-,'"constmction;only 1'GW l is needgd Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if,necessary';
drilled ( 24.SUBMITTAL INSTRUCTIONS •tc E' , .- ,.
9.Total well depth below land surface f y 3 (ft.) P.
Far multiple wells•list all depths if`different(example 3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following ••-
24a. For All Wells: Original fo i to Division of Water Resources (DWR),,
10s Static water level!below top of casing '.. �® ft. -�'• '
s '. Ij wafer levelas above casing use"+" ( ) Information Processing Unit,1617 MSC,.Raleigh,NC 27699 1617
1I.Boreholediameter: i-(in.)Bit Off: [y. I.vC3 24b.For Injection Wells:Copytoi'DWR,Underground'Injection-Control:{(IUC) ..
Program,1636 MSC,Raleigh,NC 27699-1636
, .12.Well construction method .r t3 tat.b )•`d
(Le.auger rotary cablg direct push,etc.) '24c.For Water Supply andopen Loop Geothermal Return Wells.Copy to the
i , • county environmental health:department of the county where installed
t •. 'FOR WATER SUPPLYzWELLS ONLY: - h
24d.For Water Wells producing over 100,000 GPD.CopyteDWR,CCPCUA, 7
19a:::::
' PermitProgt'm,1611 MSC,Raleigh,NC27699-16 11Vlethod of test: s70% hh eVied - -iR'� 213b. type: Amount: G 3 oz Site Visited By. --le.h _ _ M
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f ' Form GW-1 Quality P North Carolina Departme�ntof Environmental ualR Division of Water Resources Revised 6 6 2018
': Price • red] m°+ .moo e.8....:.. •J.a .�=ue: _ - - , "4'
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