GW1--05549_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
e 1.V ontractor Info lion: 1
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Well ContractorName✓✓ FROM TO •' DESCRIPTION 04
115 6 6K v� 22.sft. ? oft 3c) 1¢��� .:
ft it I' ow
NC Well Contractor Certification Number
::15.`'0171-ER:GISIN FROM TO G`(Fu'c�miilti`"cased;iveIIs7C�""licalilifk'•,:,`_•' _. ��
Yadkin Well Company, Inc. .DIAMETERTKllchXEss MATERIAL
• Company Name 1. 1 ft. '7 ft �6 a S in. ..✓� C.` ��
i q�1 alINNP.R:OSI Ili'OR IIBDIPA nt]iecmiil'clo'"seiiloop}•-::;::;.� :......_-:`a �.
2.Well Construction Permit#: " `7`7 v v �M TO . - DIAMETER TRIMNESS M?TERIJLT`
List all applicable well construction permits f.e.UIC.Caw*,State,Variance,etc.) ft ft. • in. •�
3.Well Use(check well use): ft. it in fm
Water Supply Well: rayactita :,,0 r ,w: '-'s'_':`", v:;:,:a : 'n[:'w .<.:��:7.-,-----�,
FROM• TO - DIAMETER SLOT SIZE TRICKINESS MATERIAL t-
❑Agricultural • ❑MunicipaUPublic ft. it. In. -
` ❑Geothermal(Heating/Cooling Supply) ❑RR/esideen al Water$upply(single) - ft • ft •
❑Industrial/Commercial CltRtsit n�err Supply(shared) r ;r.,;_,r s•; a -
' ❑luigation ❑Wells>100,000 GPD PROM TO TERIAL EMPLACEMENT MET HOD&AMOUNT •ft Non-Water Supply Well: {t /7 L �l �.o- $A
[Monitoring ❑Recovery ft ft •Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑A uiferStora eandRecov DV Barrier %'19l.SAND%GRi VkLP.ACM(iba"`hk1b1ejy"i::_........................................:
q g Recovery ty FROM TO MATERIAL EMPLACEMENTMETHOD�
DAquifer Test ❑Stornwater Drainage ft it. '-k
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(ClosedLoop) ❑Tracer c.-20:DRTf,YINGI:OG(attach`saeItt'arilieetiifilec'rss'sry) .
❑Geothermal(Heating/ Olin a ❑Other PROM TO • DESCRIPTION(eclat,hardness,soil/rack type,Ruin size,etc.); .
g/ (explain under#I21 Remarks)
Date Well Started- (3 fr. 9 ft ('✓ �,
i4
• 4.Date Well(s)Comple ed: d Well ID#A ik Q r 56 ,Q ft "z.® ft 0 a ' ....'e. .; t.1 R-
5a WeflLocation �sf� +do "Phone#:.�3�9'f7.-4, 02- " 1 ft &) ft air,I' W�' - SEP 3...�"'
ft 9 2 ft ¢ .e i 4'O24
6-hx+e Eaa.4 (1.KfecoiffNk I-12 hrtejf&Label., .ig 1ft ft • 7t `-
Facility/OwnerName - FacilityID# if rah7r v► i "`'`'r='( aPI ) `2 �j �SiH/7 v� �i::._, ^r y;_y
4/0C P/eaitif,.i r 9L2. ( sj Re�:4 2.2s it
t3 S ft C)--P1--14 # e 1".e . f, 2�.r
Physical Address,City and Zip NC gcacritit2.3. . ft 3I Q--f t r fi.
County Parcel Identification No.(PIN) • ,4)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .C tificatio '
• 3C. 3J I N Teo R4OLl • .4.1a4,12---- 'Og--i3'� ei''
6.Is(are)the well(s): immanent or OTemporary i e o ed Well Contractor Date
B signing this font,I hereby certify that the well(s)was(were)constructed in accordance with t
7.Is this a repair to an enisting well: DYes or 61349 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
' If this is a repair,fill out.brown 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 details: 1, .
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info r.
construction,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:
drilled rl 24.SUBMITTAL INSTRUCTIONS • .
9.Total well depth below land surface: �an (ft) Submit this GW 1 within 30 days of well completion per the followings
if
• For multiple wells list aII depths different(example-3Qa 200'and 2®100)
1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below tap of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing use"+"
11.Borehole diameter: ( (in.)Bit Off: Se. i' i C) 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
p� Program,1636 MSC,Raleigh,NC 27699-1636
00
12.Well construction method: AiP.!,' b 7 0 AM 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 Fp
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA -
Permit Prograrn,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) .30 Method of test: � r Ir
o - Date Site Visited: 6 'r -'2-
13b.Disinfection type: 70/o hth Amount: OZ Site Visited By: /)',W l.i
Form OW-1 North CarolinaDeeartment ofl;nvironmental Quality-Division of Water Resources i Revised 6-6-2018
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