GW1--05565_Well Construction - GW1_20240913

WE%,I,CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Info/
tron:
6JJituii ) a...-10" .14.WA'C '7ANE5?7V : t. •. :
V FROM TO DESCRIPTION (®
Well Contractor N 'e ft. i 3,0 it 14 S 0
[ S 6 6 -6 • ft ft d
NC Well Contractor Certification Number 1:yri?OUT1o:1?ASING`.(f Erialiftriesed'weIIs7`:ORT !IP.Iti(irii le)::.:.,''• .. ..
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS TERIAL .5
.4-i ft f ft G 4t5 m, sl'p.../i ry�
Do
Company Name a16c;IlVNI��GASING:ORiTIIBILTG(�eothermaldo"se�laa-p�"..: ,:_'4:;;::5 ;:. ...•.. ..
2.Well Construction Permit#: P g W i_`0 2-4'0/(C)5 FROM TO . ,DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UJC,Cau»ty,State,Variance,etc) ft. ft in.
ft. ft. in.
' 3.Well Use(check well use):
Water Supply Well: a..:7S. :�:.Z....., .-,:,,,,;'• ",;:l:.`iz ;:<. , -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Pnblic ft ft. in.
❑Geothermal(Heating/Cooling Supply) kdesidential Water Supply(single) ft ft in.
❑Industrial/Commercial DResidential Water Supply(shared)• ;ie9CitOUTti•.: ::
❑Irrigation ❑Wells>100,000 GPD • FROM TO TERUAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. �S ft. e. _ t a� e „- a r p S
DMonitoring ❑Recovery ''✓✓ ft ft �"W` ►`C I
Injection Well: ft ft
❑Aquifer Recharge •❑GroundwaterRemediation -19:sANI)IGRAVFJac (isPPics�ilej.:=a':- ':• :::' , ..._. .
DAquifer Storage and Recovery. ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD '
DAquifer Test ❑Stormwater Drainage ft ft
•
❑Experimental Technology ❑Subsidence Control ft.. ft
❑Geothermal(Closed Loop) ❑Tracer ':20:DRIT,i V&1OG(atfacii sadism"nnlslieet's'i nie-efeosafy)y'.•° =sa:;e:i` ,l; ''
❑Geothermal(H olu1e •'o'other(explain under#2I Remarks) M TO DESCRIPTION(solar,hardness,salllraek type,gain etze cit.)'..d ,.'
Date Well Started / 6 ft lU ft 1 �� SEP I ' 2024
A� r• Ir.,•-•r,.,.
4.Date Well(s)Complete o -- ", Well ID# ��V '3 r ft v ft p } r
5a Well Location: Phone#: 3,)-C Y(C-/195 G ? t� g i ft f i k d D''. • •��r +- �,..�eICI I Gil.;Idlee s.� ee, ft 97 fttr-.4e (50-F_71,
Facility/OwnerName Facility ID#(if applicable) 16(1 ft ti 6'°� ran;
G [ V.Sc:Id vCot'l �� .7-Li!, /t1 G`La ft ft 0.0
Physical Address,City,and Zip ft ft.
OCI
st23.'EI�MARrra-.':' ..•,!" • .E _. ,_. .
NeY
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.ti
s cation:
3G r 39 i Iw .4 dl�i_O? r2, IA se e of .-....6.Is(are)the well(s): ermanent or ❑Temporary
r' ell Contractor Date
By sig,ping this f• n,I hereby certify that the weII was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or 11114 15ANCAC 02C.0100 or ISANC,IC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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:
8.For GeoprobelDPT 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled_ i 24.SUBMITTAL INSTRUCTIONS
9-Total welldepth below land surface: l 4/J - (ft) Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths if diferent(example-3 a©200'and 2@l00)
24a.For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: kit) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,uses"+"
11.Borehole diameter: Co (in)Bit Off: _3 . q O 3 24b,For Injection'Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636 •
12.Well construction method: Air 4r er 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the obA
(i.e.auger,rotary,cable,direct push,etc.) county 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
• Fa
13a.Yield(gpm)
5; Method of test: a .r Permit Program,1611 MSC,Raleigh,NC 27699-1611
70/o
o hth oz Date Site Visited: 7 2-
Site Visited By: i/`+ '�
• 13b.Disinfection type: Amount: �
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Drina- 14 '7 REa'a "1 MI