GW1--06150_Well Construction - GW1_20241014

. . WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
I
1.Well Contractor Information: I •
S1-161,I` rl4t WA7 '7ANES'.: :;ti;.'•: 1: ,-. .i':'•.'-: . ,
Well ContraetorName FROM TO . T DESCRIPTION
I-1610 v 1 b it I IJ. it h1tdl !f ir�ta-�L / 10 spin
� U
NC Well Contractor CertificationNumber l��ft �:� it )� vr� / r
I.15forma (2 SING`(foc$aulti;'ea �sed;weIeIIi/'�)`:OR IERi(ia"'IiJ ' .
Yadkin Well Company, Inc. FROM TO DIAMETER TRICE:HSS 1 MATERIAL
ft. ft. in.
Company Name
'J.6LS'IrIN :C9SINGOR:.TE1)3M ge itIiermal closenrit pr,-,..?r :"i:•1-�::: :: '
2.Well Construction Permit#: / 7 Z. �q�::6 3 PROM TO . DIAMETER THIC[ SS MATERIAL �'rt7C g
�j List all applicable well construction permits(i.e.UIC,Cowlty'State,Variance,etc.) 9 1 ft: 6 2 ft 6(Jt,, in. 6, 1a el l' i
f`7ki g J
• 3.Well Use(check well use): fi ft. ft in ®6t
s/ s P S/ E rs, v .. .. :,- ._--...-. -
Water Supply Well: �:,•:.: ;_t= r`......€:�:^:r:a r _
FROM T A SLOT s TIRI 5 MAT
❑Agricultural DMunicipal/Pablic, ft, ft in.
❑Geothermal(Heating/Cooling Supply) ' $Residential Water Supply(single) • '
' ft ft Sin.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
ai18 G`12CSUT3:yt:' ``:`•r y,... 1 .:._.
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:-,-, s • .- _ 0 ft. ft
❑Monitoring 1 u'; .t. Y i._." ':r0Recoveiy ft ft , z a - �.�s•�.f
Injection Well: •- , '® -
❑AquiferRecharge O C T 1 '; 2Q9l`reundwatei Remediation ft ft i t/l fi t. I/{�PeAei
❑Aquifer Storage and Recovery ❑Salinity Ba> ier i•YL:SAND/tIkk. A"( (irapili cu"bf e}5..w . :, ``z. ;:;;,... - -4-.,r:, L�''
!fdReco e. _ '-„' + Sr i FROM TO MATERIAL EMPLA•r METHODS •
❑Aquifer Test ^er�'f Stonnvtater Drainage t ft.
I7Expeumental Technology ❑Subsidence Control ft.. ft
❑Geothernal(ClosedLoop) ❑Tracer f=20:DR13 �GLOG zttiic hs3ditio`rii1sieeL4iC "cessay ."^"'--i;1::=. S:�;. -
❑Geothemrai(Heating/Cooling FROM TO DESCRIPTION(ceIor,hardness,sal/rack type,grain size,etc.) -
• (FI g/ Return) ❑Other(explain under#21 Remarks)
Date Well Started q-2)-2. ,�N ft ;
4.Date Well(s)Completed:1"23• 1f WeII ID#MSS'" 3 o a tt. ft 4,)cii 10(k
5a.Well Location: Phone#:q 17®'-q 61,47tS• h.O ft. 115 ft pvrpre-. root. 60--4-
C°tirAa, Fitor es l I s ft. 26Z. ft dwk- Vou- 5O AL •
Facility/OwnerName Facility m#(if applicable) ' . , ft. ft
s
CiGitn �/ �a T Drive, o,�� L.
0.0,-'4. f ft. ft
Physical Address,City,and Zip or I6�IV ft. ft • .•:
Qo:-Q'L •
- - - -. - -. .4t4.5- i>21x'RFMA131Zfir --fi'_.- _. :,ki-T .-.w. ::'11..•z>4,-t.'r`.,71..-==Y=r' L=•e_
County Parcel Iden1iflcatin No.(PIN)
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: .••
(if well field,one lat/long is sufficient) 22.Certification:
36 ° qi I ifi N g 6 p' 37.E 5 - W
Cy-2I-2 G/
6.Is(are)the well(s): 'ermanent or OTemporary
Signature of Certified Contras or Date
By signing this forte,I hereby certify that the We (s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes -or Io ISA NCAC 02C.0100 or 1SA 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 remerlm 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 G pW 1 is needed; Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a‘ (ft
For multiple wells list all depths ifdifferent(example-3( 200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the fallowing:
Q ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft Information ProcessingUnit,1b17 MSC,Raleigh,
If water level is above casing,use"+' pp NC 27699 1617
11.Borehole diameter: &y (in.)Bit Off: 6..2.y0 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636 .
C '
12.Well construction method: it.9 r Ill +64P 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
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DW
R,CCPCUA
13a.Yield V
(gpm) 6 1) Method of test: , Permit Program,1611 MSC,Raleigh,NC 27699-1611
,
70% hth -7 Date Site Visited: 6- ►7.' ,2 9
13b.Disinfection type: Amount: Oz Site Visited By: pt,jB !
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8
Price: _ An.. -A_ as_.. t.I igde..f