GW1--05559_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1
I.Well Contractor Information:
Well Contractor Name
mom TO DESCRIPTION
/ ft. ft 1
'0 3 6 ft ft -
NC Well Contractor Certification Number ;'15.'OUTEI;:GASING`(fdi•`muIti:ce edl,ellifDR'I;INF (ifa"licatilef ..
Yadkin Well Company, Inc. FROM _ TO ni nTER THICK ESS MATERIAL
�t ... �'"
Company Name all�j �j /�
3 A �l INNER3GASINGblt:w3ING:'(geotlier'-m' 'tloiia;18 p)t.i c:.g.'i. :
(
2.Well Construction Permit#: FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.t'JIG County,State,Variance,etc.) . ! ft 6 a ft 6` ei m sig- ©2► �Psr(,
• 3.Well Use(check well use): ft it in �/
Water Supply Well: .17..lC3tFE ... '::r:.r::�;t�r= .':L:a., z_i"•,'a L:., w•. --, :::::..- .K_::•.-..0 .•
FROM TO DIAMETER -SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft;....,...' ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) "'it. ftto in:— �.„.....
❑lndustrial/Commemial L�4Residential Water Supply(shared) ; r
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAT. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. , 3 it j -t 1 L `n _- G%..,Y°; I
❑Monitoring ❑Recovery ft tr ft. se,/ c ;sI- Sr6-
Injection Well: - atlil �/�
❑Aquifer Recharge ❑Groundwater Remediation •
ft—LB�R �° .k e ���' t*.q a� 2��S
!'19::SAND/GR9VJ 1PYALZ ale) .. „_!..: -" .w "?;':'-; '
u
❑Aquifer Storage and Recovery ❑Salmit Barrier PROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft V
❑Experimental Technology OSubsidence Control f
❑Geothermal(Closed Loop) OTracer EaolomotraiGioo(iitti ih`a3ditionalslieets tf nece-siaiy) . .:T t-
• ❑Geothermal(Heating/Cooling Return)- ❑Other(explain under#21Remarks) FROM TO DTSCIt1PTLON(solar,hardess,salllroektypegrainsizeate.)
Date Well Started 8- 4-d ai f 1, .® fr• f'o ft .'a `/
4.Date Well(s)Completed: K-cam-,2.ef well10## ,ei c•�.� eo fr' da it a /,q Cj r�J„t,
5a.Well Location: Phone#:��I -9�7— 6 �� ft ft b / r(a& as;e,i 105e it-e,
ft. ft,
i) ,j u u.r Q-a\ • ft. ft '
Facility/OwnerName Facility 1D#(if applicable)
ILI®4 Ann Q,n bow /'1 Ln W p F-.`
Physical Address,City,and Zip a q(q ft ft. ��
1/M �� Q� O ':2141/1 �HKS .
tt - —J - ..'i'.... i. :.. j;111:�11':.:a l,2 ::._.'t >�..� .cs';'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - - C'N ,1(
(if well field,one lat/long is sufficient) 22.Certification:
36c t9 ` it.rii N i'Ia Sb1 4.3°' w ' ,09 y
6.Is(are)the well(s): Permanent or OTemporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o . 1SA NCAC 02C.0100 or1SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out blown well construction information an 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:
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
construction,only 1 GW- is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SIIBNIITTAL INSTRIICTTONS
9.Total well depth below land surface: (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(trample-3@200'and 2( 100)
r^� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: &l (ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: ( (in.)Bit Off: 4, /A,- 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 •
r 12.Well construction method: A t I CC)"I'G.t"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 WELLS ONLY: • 24d.I+or Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I Method of test A' G.._
70/o
o Date Site Visited: '® 19 2'1
hth oz
13b.Disinfection type: Amount:' Site Visited By: Ad
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
DAnci• , t