GW1--05547_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Con.Vactor In lion: . 0
Nita
C-40(3 i V°"lb ri.I4i WATE2020/i0V1.2i,F:',;:ii
FROM TO .•' DESCRIPTION
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Well Connactor sine
• 3Sit. 3.5/ft. 4 P.-C.1.CA'LIT. V%1 6PAI C je:Sf"
1151)06 le+ ft. ... ft.
NC Well Conbactor Certification Number I 3,5f OITTER&SINGIfirradilitriiiradfiveRS):011:LINEVer.re-ililn••.',,----- ' • q -•
Yadkin Well Company, Inc. PROM TO .DIAMOTER TEENtICNESS 1 MATWI4L
ft. ft. in.
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CompanyName
i65NRINOASI' LIVOR:111BINGablitlfirnihr elaiirTaiff- -:.....-•,' ..- _ : .--•.'. : 'i., ,„
2.Well Construction Perznitt 0 2.0 9 ail' . 2 0 11' MOM TO . Prim= mammas nu razz (7
List al I applicable well construction penults(Le.WC County,State,Variance,eft) -FI b.3 lt• to NI in- 5DR-2 t - We- 3
tt)
• 3.Well Use(check well use): ft ft in.
Water Supply Well: PROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL PI
ClAgricultanal CIMunitipal/Pnblic ft ft. in. -
OGeothernial(Heating/Cooling Supply) 111/Residential Water Supply(single) ft. ft in. '• .
OIndushial/Commercial °Residential Water Supply(shared) iAgraitoijr. •,,.._
Oltrigation °Wells>100,000 GPO PROM TO iirxrirails EMPLA.CEMENT IVISTHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 ft 1,30 opt 9 tavay ,A,2,84,51/5-
ElMrmitoring °Recovery ft. ft.
Injection Well: '
ft. ft
°Aquifer Recharge OGroundwater Remediation
1'19.SANDAMVEDIVAtietirnrioliailer
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EIMPLA.CEMENT Ammon
°Aquifer Test OStorrawateiDrainage
DExperithernal Technology OSubsidence Control ft. ft. ' . ,
°Geothermal(Closed Loop) °Tracer f'-20111BILLMGIOG(ithielifiddltifiriaralfeeti if iiYI:•..-_,1• -_ . •
°Geo FROM TO DESCRIPTION(color,'artiness,soil/reek type,grain dn.de.)
thermal(Heating/Cooling Return) °Other(explain under 4#21 Remarks)
Date Well Started /-A"-A61._ 4, ft. al. ft. f3r3i‘ , •
••
4.Date Wall(s)Completed t1, Well M#AAO-SO* 0.1 ft. 21.1A ft• SAA,V:le
. ,
hone#: 3a(-51-6C-0 3:7Q ft. , ft. '
52.'Wel/Location:
Th4 yhiv Poill&erter ,
Facility/Owner Name Facility M#(if applicable) ft. ft. i" • ---' --
2.9oq Favniing)4c4.i AA itaciklktvl'it e ft. ft •••-,. k . ,,,! .
....I-. '' °I,:.--' ' •,
ft. ft.
Physic,a14.ddress,City,andZipe 6'EP 1
ri‘ci X t ti‘ '.....IntEtallES:-....•,-----•;',• L'._-...'•:- , - -10:--•l'.-:••-': -•• '' 2n4
-' .
County Panel Identification No.(MN) C-i--. • -;..,.
.":..„,1,-.. • -..-..u . -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,-„.....3 . ,x:.,, G......
(if well field,one latfions is sufficient) 22.Cedilla:1110 .: 00 '3‘• 0 6 s?/9 N r4 0 0 kr 2 2-2-et/ W e-`4‘.'S--- - -
,..
Signature of Certiad-Well Contractor Date
6.1s(are)the well(s): permanent or OTe.mporary
.13y sip,thigthisfonn,Ihereby ocr0 that the well(s)was(were)constructed*:accordance with
7.Is this a repair to an existing well: °Yes or /110 ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a main fill out known well construction information and explain the nature of the of this record has been provided to the well owner. •
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repair under il.2.1 remarks section or on the back of this form. .
23.Site diagram or additi .
onal well details: ' 0
You may use the back of this page to provide additional well construntion info r
8.For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same
construction,only 1 G1741 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if nectssary. E.
chilled: 1 24.suamorrIAL INSTRUCTIONS - --.
9.Total well depth below land surface: -.7. Iv,
(ft-) Submit this GW-1 within 30 daysof well completion per the following:
For multiple wells list all depths I!riff:Arent(example-3 00'and 2®100, ., .
24a. For All WeBs: Original form to Division of Water Resources 10.Static water level below top of casing: IS (ft) (DWR),Information 12rocessing Unit,1617 MSC,Raleigh,NC 27699-1617
limner level is above casing,use"+"
11.Borehole diameter: 6 (i1.)Bit Off: Si st72-
24b.For InjectionWells:Copy to DWR,Underground Injection Control(IUC) CA
Program,1636 MSC,Raleigh,Ng 27699-1636 . "....„..
12.Well construction method: A r if Ro'Loy 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the .-...,,,
(Le.anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed . r1)
FOR WATER SUPPLY WELLS ONLY: • 24d. or Water Wells producing over 100,000 GPI): Copy to DWR.,CCPCUA --- -'
i3a.Yield(gpm) ••••.) Method of test: i
Ar-. Permit Program ,1611 MSC,Raleigh,NC 27699-1611
6.-e' 44
70% hth /"XS'Cif in,+
13b.Disinfection type: Amount: ) '''' OZ Date Site Visited: 8-1 -2.Y'
Site Visited By: - DX? . .
N-dif
V)
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- " - lina Departnsent of Euvironmental Quality-Division of Water Resources Revised 6-6-2018
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