GW1--06017_Well Construction - GW1_20241011

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: '
f.Well Contractor Information: (b
14....1i A") r.W f11 tsl4.'.WATF `ZONES *S c^:.'f ?'-!' '.
WellContractorName FROM TO DESCRIPTION
10 ft. q')f ft Z 21zr
NC Well Contractor Certification Number m-
Yadkin Wel1'Company, Inc. :'°1$`Oo�R;�Cnsnv `(f�:m;iiti:�ea�we>v-�:OR'z�v1E:x;�(;f:~:3"u � t��•:;:::. ("
FROM TO DTAMfer Ru TffiC$NESSMATERLAL CA
' Company Name �:t X'6 3G-C 4#0 ?G P 2 m
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06`.III :CASINGbR;TIIBIDICr:"(ge itiieTmaTdo"sgllan 'd...�-.':•5
2.Well Construction Permit#: 7-1 a.0 7 L4)NII le-1 )'M IS' FROM TO . DIAMETER THIMIMS MATERIALZ.
List all applicable well construction permits�•e.UIC,County,State,Variance,etc.) 4 I ft y�fd�a rP ft o6 S// �A in. oar--
�P 4 L ff ig t
3.Well Use(check well use): ft. ft
Water Supply Weil:
a l: .dt.ia r a-r-,,.; = Part•:`.:`::r .::.7::..•:. .i:�.": ..,_ . :,.;?11 ?.t..
FROM TO DIAMETER, .-SLOT SIZE THICKNEss�~ MATERIAL
❑Agricultural OMunicipal/Public ft in-
❑Geothermal(Heating/Cooling Supply) t esidential Water Supply(single) ft. in.___..__'____ ,�'
❑Industrial/Commerciaj t^ > fResidential Water Supply(shared) ,
d .�no.,, ...'fl..:.. V. 5,.., ti18n.G`ROT)T::��3°a�C:a e:.c�;c,•.^��'_ ;r.. "��'.:'t; `,`�`Ttit�r � "._:._-'.�" '^ "`..
Dlnigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
• Non-Water Supply Well:
0 C T 1 _ 2024 0 ft3 ft. 4 .a/ . C5 6,,r_,,.)
❑Monitoring DRecovery 3 ft. 3 ft Led eel/7.s- -Si° en;,a„
Injection Well: In ..i:- , a -;
DAquifer Recharge D':...,"- GGroundwater Remediation - -
OA uifer Storage ❑Salmi farrier i'19:SANDlGItiiie:u`F,i►:L•`wcsfzpr`hSth e) s3;1 >:-f . .,: e__ztJ.:,:.'��.:- ,
rl_ g Recovery tY FROM T MATERIAL EXPLACEMENTMETHOD •
❑Aquifer Test ❑StomtwaterDtainage ft,
❑Experimental Technology OSubsidence Control ft.
OGeothermal(Closed Loop) OTracer :20:D12.1:NGZOG(iittuciiadditio ..._.._'.: .
naI"siieefii'i£nec"eis"ary)`!;�� '�r-
FROM TO • I DESCRIPTION(color,hardness,son/rock type,grain size,eta)~^ '
❑Geothe..rmal(Heating/CoolingReturn) ❑Other(explain under#21RemrIcs)
Date Well Started ' �4�",9Z 1 p . 0 ft ® ft i Sir,
4.Date Well(s)Complete ��1Z.fri; Well yA(C- 2® . / ft z 54 ft 6ril;g% A ,td
�s�i,/2,�q Al c�q✓! ,
lead 5a.Well Location Phone#: -3%- "1-C773;. i.gg fr. ft '
- -&1r;a, ie.t, .(.dui I11V Zia) ft. 26 2. ft. ,Q/1w .1- 6 restesTk, - C
Facility/OwnerNaame q Facility ID#(if applicable) ft. '•' .ft. ' •
ti.
cG �2 c v' lc..ed oct-Cl bk. SC,vi/D1CM ly.&.Li� ft ft. ' • i
Physical Address,City,and Zip ''13 ft.
6-0-i I ' r-& . . 21.'�2 - ..„,°:' .....?,,,..,,:':.,., :t._.:cr .._ .., ..�..._........................
County Parcel Identification No.(PIN) 0.pre r$Ng� (Li i COCO.//vts a p art p1es p,lam,
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5b.Latitude and longitude in degrees/minutes/seconds'or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
3‘. 2-51210k • N "78 a 1160 3 . w • Le),--- - '82:9/2-1
•
6.Is(are)the well(s): permanent or ❑Temporary Signature of Certified Well Contmbtor D
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or 1214 15d NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell out known well construction information and explain-the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
constmction,only 1 d 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled 24.SUBMITTAL INSTRUCTIONS .4
Z.9.Total well depth below land surface: 2‘ (ft.)
For multiple wells list all depths ifdii erent(example-3 61200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
jQ 24a. For All Wells: Original form to Division of Water Resources (DWR), w0
10.Static water level top of casing: (ft•) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617 - 0
If water level is above casing,use
11.Borehole diameter: : .)Bit Off: 6., 017 24b.For Injection-Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NO 27699-1636
12.Well construction method:A I,2a-4ei!, 01414. 24c.For Water$apply and Open Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
�5� 24d.F'or Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) �� Method of test: try al Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited:
13b.Disinfection type: Amount: k OZ Site Visited By: .
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Form GW-1_ - /North Carolina Department__of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018
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