GW1--05652_Well Construction - GW1_20240912

1i'
WPFrL CONSTRUCTION RECORD_(GW:1)' For Internal'Use Only: . .• •
'Contractor Information:
oily
sm" wii-c'4��- ,,- •?,:,
4 e ., . .• .
i_WATE$`7,UNF5 2r :N"
- - • •
FROM _ TO . i CRIPTION '�
Well Contractor ame .
lContr NC Welacttoer �
Certification Number • "., ,'155011 i v(.SING
'S °(fo muliic'"ased4wilL�DRIi�TF C P"4m"ble t...;. ..
Yadkin Well Company, Inc. ,' FROM ::T0. ___ 1WM rER :TmCKIWSS MATERIAL
ft. it
Company Name •:a u 's ralldVffit.CASING-201 FU3Tha tidthermireecliii 184L , 'j
2.Well Construction Permit* f2 T �: 5 FROM /D TRICK aSS MATE
al all applicable well construction pesnuts(Le UlC Catoriy5 State Variance.etc) It Q < I
' 3.Well Use(check well use): t in `
Water Supply'Well: k s, s.: ._..` _ e •_ �. _
FROM TO . DIAMETER SLOT SIZE THICES ESS MATERIAL
❑Agricultural ❑M,Iimicipal/Publie , ft. . ft. In.
❑Geothermal(Heating/Cooling Supply) ritLesideatial Water Supply(single), ft. ft . l•
❑Industrial/Commetrial •
❑Residential Water Supply(chaired) ;YB t�S11T:: ___
❑Irrigation ❑Wells>100,000(IPDI . , - - .FROM TOi .,EMPLAC IWIZITMETEOD&&MOUNT . • 1
Non-Water Supply Well: • r ` •-
❑Monitering , ❑recovery >_ __
Injeetion Well: i
g
❑Aquifer Recharge .,..,17Grouadwater,Remediatttm; 't - '
i19:SANDfGRb;,- �(fb�►e'�rcfi�f�u$• - - '; `'.
❑Aquifer Storage and Recovery •,'•❑Salintty'Barrier FROM- TO _ MATERIAL .. EMPlLACENILrNTMETHOD_ _ . • .
❑Aquifer Test ,- OSto>mwaterDrainagy• .
ft. fr.
❑Experimental Technology - DSnbsid'ence Control ft., it.
❑Geothermal(Closed Loop) OTracer + "20:DRTi 141;QG:(a"ttuh fiddltlntial3lieetiid'neceifaifl': L vaa't' ':-._ i
•
• ❑Geothermal(Heating/Cooling-Return) ❑Cttier(explain uncle;#21 Remarks) (�Ioz hazaz;rss;sotumcls type, size etc.)
FROM TO' .DESCRIPTION
Date Weli St•arted L'I -' -
4:Date WeII(s)Completed 7: . Well ID# -art R _
Ss Wel'Location: . .� 7V:.-'2 9 `/`. • } i
}
h 2cn cap% - SEP I 2, 202
Facility/Owner Name ; PacilitylD#( applicable)
6 -q `,-h je ' Lec,icrri/lz.- _14+ . Ir„^ :.:i`t ' IJ�
,1,-: Physical Address,City,ad Z nip- e1 riOn ff. D'r
County405
:' ,' Panel1rt-nt;fir•ationNo.(PIN) / Q .hW1� _. . 'il t.. ,
• Sb.Latitude and longitdde in degrees(minutes/seconds or'dech-nal degrees:- 20o1 A_nrty"ct Cap.:, - - - '" .
(if well field,one ladlong is sufficient. ) 22.Certification: '
•
6:Ts are the well s - Signature ertified Well-Contractor Date
( ) () i ermanent or ❑Temporaig ,, A„t r
Fav i v' Dy signing:his fom,I hereby certify that the ewell(s)was(were)'cpnstructed n accordance with
7.Is this a.repair t 'an existing-well: DYis or I Nm- 15,4 NCAC 02C.0100 o'r ISANCAC 02C'.0200 Well Consbuction Standards and that a copy ' .;-�
If this is a repair,fill out laiown well construction information and explain the nature of the oft his record has'been provided toth'e;well owner. -
i
repair under421 remarks section or on the bock of thisformi. 23.Site dia'"am Or additional Well details:
You roily use the back of this page'to provide additional well construction mfo, .
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells Having the same ,N �� .
constrnctioa,only 1 GW is needed. Indicate.TOTALNUMBHR cif-Swells (a See Over?m Remarks Box):Youmayalso attach additional pages if necessary. _
j
drilled: / 24'.SUBMITTAL INSTRUCTIONS
/50a ft:,
9.Total well depth below land surface: •
( )- Submit this GW-1 Within 30 days•of well completion per the following: • -
Far multiple wells list all depths if different(example 3Q200'and 2(g700),
{ 24e. For All.Wells: Original fat& to Division of Water'Resources•(DWR) i',, ;_i
10.Static water level below top of casing:_IS f_-__ . . - - (ft)' I f�tionPiocessing Unit,,1617'MSC,Raleigh,NC27699-1617 -
If water level is above casing,use"+"
241i.For Injection.•Wells:Copy to;DWR,Underground Injection Control(1UC) .
11.Borehole diameter: (m:)Bit Off:.i..a q 'd r - Proms;1636 MSC Raleigh,NC 27699;1636 '
12.Well construction method: r .0 0 rtj -. - - 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 y..
FOR WATER S U.tPLX WELLS ONLY: 24d.For Water Wells prodncing.over 100,000 GPD:Copy to DWR,CCPCUA
ry t ,Permit Prograrn;1611 MSC Raleigh,NC 27699 1611 . - .�,'',
13a.Yield(gpm) 'c Method of test: IT1'�- - , ' -.t -r•
o Date Site.Visited:� I'-2y
-� - Site Visited,B
13b.Disinfection type: 70�o hth Amannt:• oZ i y
P�(4 Aar 4-S'etu fl r
Farm.GW- ✓_ /' North Carohnu Department of Environmental Quality Division of Water Resources, .Revised 6-6 2018 `
•
`+:.