GW1--05568_Well Construction - GW1_20240913

`i 1.L CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 ' -
:
1.Well Contractor Information: /�� f
DO d L )( I I(cI► - ' J1 LA / l, 1r 14r'.WA1 `TONES i>'n' i..'.
FROM TO DESCRIPTION
Well Contractor Name
ft. 2voft o
---------- ---- -.--._.-..A — — ff.-
• g f� j - 'i --- •- -------- -- -
NC Well Contractor Certification Number e l -- —
1S:OII7 :@1i1SLNG`(foznmlii.sei*ie•I`:GIttaNERt'(i ir—liMIef., .. -- •.-
Yadkin Well Company, Inc. FROM TO ,DIAMETER I THICENESS MATERIAL
1 1 ft. I ocA it. G, a sin. tiists,,,.414 krteet
CompanyName •pp yY ^y a16`Il�N�It:GASING.OR;TQ$INGi((eotlietmal clo9eit=lhop)•:. ?`s:::•;-::.
2.Well Construction Permit#PIS(/n, L.. 2.D✓` - �+t) S f 3 FROM TO • DIAMETER THr( SS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft it In
Water Supply Well: cIN,SO4 tl,11 .c_.,__;_. ;_.;y l'r.�._'_.__::'.:::1-; ; �:'-..;'"2°:0:1::i';Vs°PP y FROM TO DIAMETER '+"SLOT SIZE';;'THICKNESS j MATERIAL
❑Agricultural • ❑�M,unicipa]/Pnblic ft ft in.
❑Geothermal(Heating/Cooling Supply) o esidential Water Supply(single) ft ft in.
❑Industria]/Coirimercial ❑Residential Water Supply(shared) '�18 G1totiT$ „_. `V',•,:._.. a; "-" __ —.
• ❑lrrigation ❑Wells>100,000GPD FROM TO MATERIAL EMP.LACEMENTMETHOD&AMOUNT I.
Non-Water Supply Well: ® ft. -Z S f beN cpi e pow-- c k,n f
DMonitoring DRecovery ft. ft. I" '
Injection Well: ft ft
DAquiferRecharge ,❑Groundwater Remediation
1'19:,SAND%GR'c$V .AGK'(>E pp1i"cu�7e)c i w 4 _ .e-;:•..':- .SAY".:L 1T.:r;.e:..
• DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL r EMPLACEMENT METHOD •
❑Aquifer Test i •• ,❑Stomiwater.Drainage ft. ft
❑Experimental Technology' ❑Subsidence Control ft. ft.
❑Geothermal.(Closed Loop), • ❑Tracer;,r,::- "•.20:DittelINC4'LOG.(attac1i`idditinnzislieetis',neiessafy)'.? i ::il-`a:;`i;; �+: -
❑Geolheimal etrtin hDe Re 0Other s -FROM TO DESCRIPTION(color,hardness,salltroek type,grate size,etc.)
(H g/C.yp g tt l, (eipla a 'nder7#21 Remarks) 0 ft. s
Date Well Started t I Li y� °� G '
4.Date Well(s)Completed: 7-I f-2 61 Well Mg . �'''' " 2.6 ft ii U ft Pi P•,}
Phone#: 336- •S"� it$ ft. it) ft. �'Ifnej �cb�1C S
5a.Well Location: ,7,.;:,f;.
cIctA .t • ; ' • `•...- • -2( ft rook ft e4 d-Ai tQ v • w'r��s f �,»
Facility/OwnerNene :' Facility ID#(if applicable) ft �e�
11 G 0 0 1 P n f4r ft ft SEP j ��
�. t e �-�r�ctr 202�
ft ft Iff
Physical Address,City,and Tip.' +` ;, it',": v .a i r
rai:2t:''RF.tiMIIKS :. .- ::'... .., �7..i .w-.. ..,.-_ .. . ..F51f.r :"t'.4 ,
County / '• ParceiIdrntificationNo.(PIN)
•
Sb.Latitude and longitude in degrees/;minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient)• ,:-:,�,t: 2• tifieatien: r
t 'l
S' CO r:efWell Contractor ' Date '
6.Is(are)the well(s): L 'ermanent or ❑Temporary r
,/ By gning th%form,I hereby cerh;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or do 1SA NCA •02C.0100 or 15A NCAC 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 render#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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: if24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /f`' (ft.). Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'annd��2@100')
(8 G (ft 24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+' 1.
11.Borehole diameter: 6 (in,)Bit Off: 5.9 CC, 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
CR.12.Well construction method: ir 111- it) T 6(` )I 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 installedZ
FOR WATER SUPPLY WELLS ONLY: , 24d.For Water Wells producing,over 100,000 GPD: Copy to DWR,CCPCUA
/'� Crs l �- Permit Program, MSC,Raleigh,INC 27699-1611
13a.Yield(gpm) �/ —Method of test: i
• 700/ hth Oz Date Site Visited: tf't` Z cl
�''` - Site Visited By: O I I °�
13b.Disinfection type: Amount: Ia.
Form GW-1 --- North �.CarolinaDenartment ofE viroiiineetal Quality-Division of Water Resources Revised 6-6-2018 W
u. Price ( irr