GW1--05546_Well Construction - GW1_20240913

. . ,. .
. '-'•- -- - '. , .
• ...• . ..
, .. • .. , .,.. • . . . ._. . ,
IALL CONSTRUCTION RECORD(GW41 'For Internal Use Only:
. .
, , . ' -- •.':.2-, . ,:
1.Well Co tractor Informatio •
trid VI p6
i -,,
•
.. .
. ..
• _._ . TO-atz - - i 'r.. '- ...:.:::',:.:::;;I:..r..,,•'..: ;.',.--;.. ''•..- ..
FROM . ...•• DESCRIPTION- . _
'Well Contractor Nam ,
•
q5tos 11-- •
..
ilia & si4aft. itkcetivt 7 CPM Clccs-( -' :,..'• -... -: :
NC Well Contractor Certification Number "1 • t1it.0133:141;:i.MNOViirrirtilii-TaiiiidiellaTOTEgiclanirlirM:
Yadkin Well Company, Inc. FROM TO: •.DIAMETER: _ THICKNESS sdAiritia.
ft. ft. '
, . .
Company Name . .. -tl6S1NNERIGASIING:0/1711111N.G.Witlfe:fidaTild'illadra,,j.::'...3y. : ,. ' • ':
2.Well Construction Permit II: O .00 :t.Ct•-•..20.g-Y - ;FROM_ . TO._ • DIAMETER THICKNESS MATERIAL - •
List all applicable well construction penults(Le.Ella Con*,State,Varifame..ela) -ii - ft. .39 IL (9 At in- 6.17)e-:0 • pot ii.•
:
3.Well Use(check well use): ,: ...
. ,... - ft. ft
- in.
-r
Water Supply Well: .. '. - - 1...Ktat.kkuairat;c:;:;,i-;::21,.:1:7;fL.a:1;11.r.;.,SIVAJ,...S;,.:C--.g..a:',:...
. , FROM -TO _ _ DIAMETER 'SLOT SIZE THICKNESS MATERIAL ..IIIIIe•
OAgdcultural
Olvinnicipal/Publie ft. . ft. In.
Opeothemial(Heating/Cooling Supply) iittesidential Water Supply(single) ft. ft. -• -
in. • - .
Oindustdal/Commercial rm' „‘•.A..0 0l oa...Supply(shared)
...;.i:r7-. ,. •---. -,----_--- -
I:Irrigation' . OWells>100;000 GPD , _ FROM, TO MATERIAL _. iitasiconsw Damon&Amman I-
Non-Water Supply Well: ' ft. •:
O. it ;' ;A. an ,Cii(v rs -goirTy d.g.
,... ,
OMonitoring oRecovery . ft. . ft. :
ft , _ .. _
Injection Well: ft. .
'
ClAquifer Recharge OGrOundwater Retaediaticin -
' - - _ . . _ •
iii.91BANIY/WitibM.N.C1017:-- -".-*-:-.;'.- - .-.. ' - ____:• ; _
OAquifer Storage and Recovery OSaiinity Barrier- FROM _ TO MATERIAL.., EMPLACEMENT METHOD ' ..4.
• , •: ' OAquifer Test OStonnwatelDtainage fr. '. ft.
1,
.i.... o.
ORiierimeixtal Technology 08ubsidence Control ft. ' ft.
OGeothernial(Closed Loop) OTracer ;fia0I-1011=N-GT.:0Glittithiiiaditliliailiee. tiiitliescliiiiiiy--T.6-:=Kii..,t7:::::.2,-,::-•- •;:-- .4""'"
; ype, W,
OGeothermal(Heating/Cooling Return) &other( lain under#21 Remarks)' FROM41"T\ - DESCRIPTION(color,hardnesssell/reek t grain size,etc.)ft sot 1 ...
Date Well Started f7ar . a , " d A,..,.‘ 2, 1 1 .
..
4.DateWell(s)Completed: e-6,-- -k :jiVell rD#Pri•_,4i- 1 6 % - ft*':44:art)N ft' s RAI,. x .
Y 5ckl-
Phone 4: -715yigsrY-6-32g ft. : ft.
.. -Sa.Well Location: _ _ ,
ft. ft r • .
- ' Viii.4av itics-k ' 4 _ _ _ .
.,.FELgiliWirjimaerNanie . c• .; .•Facility ID#(if applicable) it ft. .' ' $........."L.; :-
_
SEl_
-'. •, - "-:,..S*51.-r6 .R.,;cci. Act 1.1075-kilpiiia, .. .. ft , ft
'' i '
tN 2n2AL. •
Phyikal'Ad&ess,oIi-iilai4-*9 .. . ft. ft.
_ „ lr,'."7::-•""''
.. ,_
; .
• , *
• ,,iy,,ei4<, . ,:.;:,, ,.: !, ,
.. . - county; ,-,: : .1''' A . • -' Parcel IdentiticaticinNo.(PIN) . - - •
- .
5b:Lalitride and longitade in degreesdninutes/Seconds•or decimal degrees: ,,
(if v;e11 field;one lathoug ii snfficient) 22.Certification:, .,,, .
CL)4. IC,.:133,11' . N. • -0 1,'C.C.2: . W - ' ' .:-9 `'..00:,::::‘ •' '
Signature:fkrectWell Contractor• - Date
• :6.iscare)the well(-s)i liiiernianent or OTemporary
•
-. ,.
.-- ' - •' - ..- By Signhigthillorni,I hefeby certify that the weilNwas(were)coh.struatedb:accordaiteeWith-
-•.''' 7.• Iithis a repair to an existing well: DYe".S or ,-.10C•To ISA NCAC 02C.0160 or lid NCAC 02C.0200 Well Constructiat Standards and thaittcopy '
•
lf iln:s is a repair,p out knOwnWell construction infririritifio toil ezplairpthe nature of the of this rem'd hasZcen provided to iliewell Owner.
P.7
'reliair finder#21 renfOrks section or on the back ofthisib', '' •
l'i 23.Site din ant or additional Wellidetalis:
i 4
8.• For Geo Yon-May use the back oethis page to provide additional well construction info-a''- ,:
' - probeJDPT.or Closed-Loop Geo.& ' ells havitg the mune
' construction,only 1 G7-1 is needed:Indicate TOIL NUMBER of wells (add'See°vein Remarks Box):You may also attach additional pages if necessary: • • •
. „
drilled: 1 4 24.sunmairtm,n4grgucrioNS • • . - - .1
9.Total well depth below land surface: .,‘: .3::27r):) .. (ft), . . •. P
Submit this GW.4 withi::::30 days of well completion per the followingi, .' , ,'• .
For multiple wells list all depths p'dfferent(examplc;3,©200?rint1720.1007
- '
at) 24a. For All'Wells: Original form to;Division,of Water Re:source&(I)WR);.,',/
10.Static water level 13 clew top of casing: , :g0 Information RrOdisging Unit,1617 MSC,Raleigh,NC 27699-1617
..
If water level is above casing,use"+" - . .
la „ .
^•• ''I' 2,4b.For Iniectien Wells:Copy*DWIt,UndergrotildInjection Control goo) - •
il.Borehole diameter: (in.)B it Off: 0.,71 h.,
. Program,1636MSC,Raleigh,Nc 27699-1636 , .
12.Well construction method:I/A i e ss24411 ._ 24c.For Water Supply_and OPen•Loop.GeothernialRetritn Wells:Copy to the- , .'
(ie.auger,rotary,cable,direct push,etc.) ' '' ' Pottnty 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 : ..
13a.Yield(gpm) -7 :.
"
4f"Method Of test: ir , , . Permit Program;,1611 MSC,Raleigh;NC 27699-1611 ' -
. - 4
70% hth i 2 OZDate Site Visited: 90%,-'8$7"Z-P
. .
13b.Disinfection type: AMount: - ' l• Site Visiteday: . ..
•
... ,
, .
„ ,Form GW-1 No Carolina Department ofEnvironmental Quality-Division of Water Resourdes' : • itevised'6-6-2018
•
Fri9C--- -. .
. , . ••
• )
__,-••••--7:( l' '*•
, ,,, . . - .-''' •'''-___LI