GW1--06024_Well Construction - GW1_20241011

WELT,CONSTRUCTION RECORD (GW-1' For Internal Use Only:
U 1.Well Contractor Infer..:;,,,: 1
eeelra.4i WATRR`ZONES' " : r i,, .. ..• -. 6.4 '
FROM TO DESCRIPTION LA
Well CoatraetorNami •
1 ft. ft e� �N NI l Y�"ait B V
La{�" d fft. ft �1• 1 Jra
NC Well Contactor Certification Number :15!ouTl :Gt(y4ING`(fo%`:mnlli;a edhvellss':ORX;INFifilia IeS;T .,.:- ' 0
Yadkin Well Company, Inc. FROM TO DIAMETER _THICKNESS MATERIAL ..g
ft. ft. ; in.
Company Name 7 3c Ts f 3 y i 7 R:CASING;OltT1JB1loite-uttierma1ilosbloop)`• . .::1:_ ....
p�° e FROM TO . DIAMETER THICKNESS MATERIAL-- ,
2.Well Construction Permit#: M v �2�® �o°�
list all applicable well construction permits(i.e.UIC Cowiiy,Slate,Variance,'etc) t" ft
• 110 ft ,°�if in. i WC.'3.Well Use(check well use): ft. 9 ft In
•
Water Supply well: ]7 SCetL& ;w'. . __'. '.: _ .. .. . .:•., --
Pp y FROM TO --r.,DTAMFCt77.R v.-SLOT SIZE• THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public I ft ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -'s;iS:zGIi6UT ` - .,::) .. "t: .. r __-: - ">"
❑Iuigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 9.0 ft' kfl di JIt 7 12 RA.
❑Monitoring , DRecovery ft ft
Injection Weil: .":' ft. ft. i„'.; : - ; s ;`--_--,
❑Aquifer Recharge •❑Groundwater Remediation c _ t ,^__ •_% ` . '. ;
1:19:.3A1QD/.u.�f'VIA,ACK(zt�o'�rCa�C7'a'.*z.=-.'`.'. ;.t�..,'_ _ -.:-'.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO EM MATERIALfn EII.A.CELIENTMETROD ' •
•
❑Aquifer Test ❑Stormwater Drainage it, ft U CT 1 f U 4
❑Experimental Technology ❑Subsidence Control ft•. ft. ir,:; ..,,;,;_r,. -. R,.. _ :'74x
❑Geothermal(Closed Loop) OTracer 20D)RttIlliGIOG Cita&anailiunal"sliee{azrieasssry)` 7?:a . »'>'.. ;;=--:'.
• ❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(comr,hardness,sail/rock type,(uain size,etc.)
Date Well Started 'a -NJ " p A 0 �, ft �Ge
4.DateWell(s)'Completed:/'� ra Wenn#/"'FAQ�1i 9 ft ft hd
5a Well Location: hone#:gx�,-$r%f11-"7 5915 ,0 ft ft 1,1)hd � ,1� &,\ • C
•
J/3 hi e_r... • to i. ft. ,`)ea f t ii,), 1 kAn(-
• Facility/ 'Name Facility ID#(if applicable) ft. ft. ..�
ft ft
Physieal Address,CYty,and Zip
i�2'`15;RRMA S.',S,''.a t/..'.,' : ..,•c::..' '•izc:.i'i:: :',-::a: f%,9.;:2 ;''.'.>'-`:'>;i`:::::;'n:
County��l Parcel Identification No.(PIN) I.'1I() 1/1 l' Lf ry �P`•)3 C{ ?//2 G1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i
(ifwell field,one 1at/long is sufficient) 22.Certification:
• .33; '-1 C s.ct,Q N Sla e t 34 4?6"(:) w ,4,2,..4_,7-7. -- q#-3t-2 ii
6.Is(are)the well(s): permanent or ❑Temporary Signature of Cent ed We]!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 8No 1SA NCAC 02C.0100 or NSA 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 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 1 is needed. Indicate TOTALNUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ® 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW 1 within 30 days of well completion per the followings
For multiple wells list all depths ifdifferent(example-3@200'and 2©1000
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use +" i/
11.Borehole diameter: �O (in.)Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 ro
cp
12.Well construction method:Air-!g•i` *1' 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 re
FOR WATER SUPPLY WELLS ONLY: •
j) l� 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
TTRPermit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 4 Method of test:
o Date Site Visited: 7-4-2,, 4�'
13b.Disinfection type: 70/o hth Amount:• li g OZ Site Visited By:_ bOV.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018