GW1--06148_Well Construction - GW1_20241014

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:pf FL
Ali1��[ �vt s19..WA.TEVZONE3l 'snza•r.•. ;':I'-.'i •
We1lCoatractorName •,..,- FROM 0 . ESCRWPTION
3 s — ft. : ft —(
NC Well Contractor Certification Number ;:15:'OU13KR ate"INPAfor:multir asedNielig:O1ailiME(iCir-lira of W;�,' /�
Yadkin Well Company, Inc. FROM TO DIAMETER , THICKNESS �j MATERIAL 1,�v
ft ft in. 1
Company Name 6Y :C-AS71IG'OR:1tJ, laWi(q$5tfierm'""1a'cloia3Ioop]��=:.r'RJ ..' w¢: ;: .';
2.Well Construction Permit#: 3S 9 'iJ.J FROM TO . DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coto*,State,Variance,etc.) '4'1 ft.
I ft 6�;SO
[O in-
1_4 4 6W $+ /
' 3.Well Use(check well use): ft ft o d'J V in. v O �l
Water Supply well: :�.1_ •�;;i ,;cg'.1-. .: S^•:''.'iz.:s.'.-'.' :IC'e— - :. ,i:•..:. ,
FROM TO DIAMETER SLOT SIZE THICKNESS fATERXAL
❑Agicultural ❑Municipai/Publio ft loin
❑Geothermal(Heating/Cooling Supply) 1811.esidential Water Supply(single) ft — ttr-- in. �,
❑Industrial/Commeroial ❑Residential Water Supply(shared) •,- nZ _
❑Irrigation [Meng>.100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyWeIIc _ , _ 0 ft p o ft. p,',1�6'.,►"1t /IA u. /
❑Monitoring; '.+
s. ,';a.,' ' ';. ;^.• oRecovery ft. ft I' `+1 ,)
Injection Well: 10 a,5 t
�024 ft. ft
ClAquferRechar�rT I. 1; OGroundwaterRemediation .___
l:!19::SAND/GRAVETi�:if:CRjiESpplicaliIa�...."... ?�':.o;:'= 'i; .-...:_'r'. `:�"bl.,,:°' _
❑AquiferStotage and Recovery ❑SaliaityBather FROM - ©n��'—
•
❑Aquifer T`eif: ":-'IL,:
.. :�
_ .'` ' `1'OStomrwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft .1
❑Geothermal(Closed Loop) OTracer c;20iD G1OG.'(attach`fiadit iiiiI ilieetiif.neces's'aiy)=;_`iL4::_':•;' i "'.LMNF.;
• ❑Geothermal(Pleating/CoolingRetnm) ❑Other(explain under#21Remarks) FROM TO DESCRIPTION(color,hardness,soillroek type grain size,etc.)
Date WeII.Started: „r i�'-X.f ft ' ft. ®a`/�. !r
- 4.Date Wee(s)Compldfed:q_f f r)4 well�D)#A4 / 3'1, ft' . 4 ft ..cc ra G 'f1t
5a Well Location: 1 Phone�#ezif;'7..7 3.gg .24 ft. .21. ft fa I P
Ire 1601/te - . _ . 2`7 32 .ft i1v . i� '��,�. & '
It-
Facility/ Name Facrfity ID#(if applicable) 3,2 ft 3 f' Sag' S 1 ,i.t
a2719 .SAtiw/. Lia l'c,rs 44
As t3 go7 36 ° 510 _f 11-rrd 9eD5r .+.; t� y0
Physicalddres,City`,andZp SUG 02- /v e1 SO 'T � o
.
03
f
County . ..' Parcel Identification No.(PIN)
i '
'5b.Latitude and longitude in degrees/minutes/seconds or derimal degrees: •
• (if well field,onelat/longissufficient) 22.Certification:
f 161 3 I N gi°) ail ' c29°1 W C(-1 0,),
6.Is(are)the well(s): 'ermanent or ['Temporary o Certified Well Contractor Date ; : :-
By signing this fortn,_Thereby certify that'the well(s)was(were)constructed in accordance with,`: .
' 7.Is this a repair to an existing well: DYes or pl, Tri 15A NCAC 02C.0100 or I5A 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 dwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (ft) Submit this GW-1 within 30 days,of well completion per the following;
For multiple wells list all depths OW-Brent(crumple-3Qa 200'and 2(4100')
24a. For All Wells: Original form to Division of Water Resources (DWR), --
10.Static water level below top of casing: rTM.. ( .
ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.BorehoIe diameter: & (in)Bit Off: (t 11 J Li24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
• / Program,1636 MSC,Raleigh,NC 27699-1636 41..
12.Well construction method: a/_/ /'IP T 47 24c.For Water Supply and Open=Loop Geothermal Return Wells:Copy tithe
(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
13a.Yield(gpm) 0 Method of test: I'J ,(I f
Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: °'2 r'2 Y
13b.Disinfection type: Amount: 10 Oz Site Visited By: ,/714
Form GW-1 North Caroline Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: ,