GW1--05558_Well Construction - GW1_20240913

te ' g�L�C®NS7C n�TCTI®IV RECORD (G9€1-9 For Internal Use Only:
mo
1.Well Contractor Iliformation:
M1140/. 6
Gt7L1/'6 g.1:4'sWATERI.ONES z';as r: :,,....
FROM .TO .•' DESCRIPTION
Well Contractor Name [320fft 12p-/ ft r .Sv B
RSO t.� ® Its . ,6 12-ft 3Q�iXe lre
NC Well Contractor Certification Number f
:li':'ODTI�;:(3ASING`(Eorimulii:c �veIIgy70RTiIl/ERi(ifa'"lic`ahle) i;V.... ..
Yadkin Well Company, Inc. PROM TO DIAMETER' THICKNESS 1 MATERIAL
ft. ft. ! in.
CompanyName �/ (� ,,''" ., • _a
3 1 p, t S' 16I NEVCASING:OR QF11iG(geotbe:a alrlosedaloo"pP,.i.:: ,q; :••s,.,,.;:""
2.Well Construction Permit#: y PROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) .t. I it I )7 ft 6.I1r in- d Ali P vc- 0
• 3.Well Use(check welluse): ft ft. in - �^
Water Supply Weil: s].7•SCf$`7::%;i3 ;£ _1;;2�::%;': ` ..i" iii� it:' -.1.7 ._ •. . .' ,
FROM TO DIAMETER)'4,SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
❑Geothermal(Heating/Cooling Supply) x.esidential Water Supply(single) ft ft. in.
❑industrial/Commercial ['Residential Water Supply(shared) x.
-
,is:.GRdirr :' J r i. ?J. :a_:: . ' ..; e a.ss
❑Irrigation ❑Wells>1b0,000'0D. PROM TO MATERIAL ) EMPLACEMENT METHOD&AMOUNT
Supply - `.,eL,; :,/'T' 1..,:'0 f' as- ft. Beth-1.111, Chips
paG4Ce
Non-Water Su I Well: I .t�... f.r ,
❑Monitoring - ❑Recovery• �,. ft ft 20 �'
Injection Well: S E R4 _:; 2024 ..
. ft. ft
DAquifer Recharge •❑Groundwater Repiediation
It`.r 'oa:Ei*ie: ,. :.:.,.':d!ts"',y .J`is19,SAND/GRi�':V�Y.�iCI�(itfipp]ica�Ie7.;:�'�t�i`-`�;,',;a.., r..,�_:, ..,•..1...:.• �q
DAquifer Storage and Recovery . ''IDSalitity-tarrier• GuArrcy;!! .G FROM TO MATERIAL EMPLACEMENT METHOD ' i�
DAquifer Test .. ❑Stormwater Drainage • ft ft •
1
oExperimental Technology •,. = ❑Subsidence Control
ft.. ft
❑Geothermal(ClosedLoop) -- ❑Tracer .�`'' .•, `;20rDRItttNG1OGatta elfiditioualsliet fifnecessary)rwi ' ::(;;a.`sr '.• ❑Geothermal(Heating/ oolin F.etum) ' .❑Other(explain under#21 Remarks) OM To DESCRD TION(coley,hardness,saiFraclt type,grain slse etr)
Date Well Started .g.1-n il "q 0 f t �v f t ea
4.Date Well(s)Completed: 6)3�-?i L Well ID#44_(3t 7O s o R' .0,2 ft 4 c Iasi/.a
5a.Well Locatt on:` Phone#' 1�'�(� 1107 ft 33 ft S;
• IV;PI/ 4M ..ACPi&bi'Oil: - 3`8 Y2 Ss' - ,,.& , ,e...a.�•c
Facility/OwnerName //• ' Facility fD#(-if applicable) / e-7 S/�`•- ft 10 R' M'Y✓r ,f O�i S•/O.i I
-.. • •;,Y. Aid?r /!t C_A/`G I.,. 6 I(9�P/°�j £,.4 WO i ft ft. v.i,( ( J °I (rri
Physical Address,City,and tip. Q/ g£ ft Ulf X ft In f a ✓G
�b U3' V U, i!`'
t:1L RKF,tex..fir .� •.f;,...: f...,... s y;;•:..::,...•_a:?: ,
County : . . - . - ParoelldentifidatiOnNo.(PIN) IS— 17 ) P
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) : . . .. 22.Certification:
• 34 , i2 3‘1:®- . N airs. 1:7137 : W t CeVtil. a- 23=11113
' 6.Is(are)the well(s): ermanent or OTemporarp Signature of Certified Well Contractor Date
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with P,
7.Is this a repair to an existing well: DYes or mfd o : ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information esplain 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells Laving the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: J. Q(� • l. 24.SUBMITTAL INSTRUCTIONS
- 9.Total well depth below land surface: U -`2, (ft.)
- For multiple wells list all depths if di,9erent(example-3@200'and 20100) Submit this GW-1 within 30 days,of well completion per the following:
(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: DV Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'
11.Borehole diameter: ( (in)Bit Off: 5 p� [ 0q
5- 24b.For Injection'Wells:Copy tb DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
00
12.Well construction method: t2%. i / to Tc.r 7 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
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells pro during over 100,000 GPD: Copy to DWR,CCPCUA su
? 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) J Method of test: r I G,l .
o • Date Site Visited: if f 24
13b.Disinfection type: ' �o hth Amount: ' OZ Site Visited By: ,vl6 f
J' ` • .
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resource f Revised 6-6-2018
Price: • e_ _ a.1- . - I i. i .