GW1--06158_Well Construction - GW1_20241014

, LL CONSTRUCTION RECORD (GW-1) For Internal Use Only: o
1.Well Contractor Informatioon:
76 dk (jj T L.LI a\f‘i rniAii,..$)::- Es..i..4',•,„ii.- ... ,...,„...,,..,... • ,_,..: •. _....•:„... _......,.::::::;„ .. .. ..,. -
Well CoahactorNan( FROM TO DESCRIPTION
NC Well Contractor Certification Number ;.18?OTJ :t ,1NOtga'm`n"lticlis-e Itielg))3 ' airliM1il.r.f.': 0�
Yadkin Well Company, Inc. mom To ,DIAMETER . THICKNESS MATERIAL ""i•
t I ft. 6 14 IL 6,1 ZS ' SOR-21 eV .
CompenyNama /+� ° 4-.6a7.iNER:CASINGDRUTI II'IG 'enthefinlirelas8tl60)1'.: r,: _;'4:�,::..
2.Well Construction Permit It: vc. L) ^� FROM xo DIAMETER THICKNESS MATERIAL -a
list all applicable well construction permits(Le.UIC,Comity,State,Yariance,etc) ft ft in- ,
3.Well Use(check well use): ft. ft in.
Water Supply Weil: zl clktIN;;...1?;- '.,-72"4.� 's: s�v�':• .. ::t se<::: ";: ti'.':�,`=�.SI ": :;::,:1- ?tom
FROM TO- DIAMETER-, �SLOT SI= ~THICKNESS ,,•MATERIAL
DAgricultural ❑Municipal/Public ft. - ft in. -
• ❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
• ❑Industrial/Commercial °Residential Water Supply(shared) 7. ifi;;:::i_ • ';:.0.:1;' ny I. ;,+'a.:� � r,:: .
❑Imgation ❑Wells>100,000 GPD MOM TO „• r "MATERIAL • 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 214 ft. edt_ r
❑Monitoring DRecovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation '
0192 SAND/GRA.vJ+ F,sfC1 (ifp calrl'e)r.:.. - .J�v' :�5:.:__:r`-r` i"s d..:k .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD - •
❑Aquifer Test ❑Stomrwater Drainage • ft ft .
❑Experimental Technology ❑Subsidence Control ft. ft. •
DGeothermai(Closed Loop) ❑Tracer :20:D11.1/ iIGZOG-(attaelsijditinaaI"sfie'eti3f•.nec"«saiyj:';:i`e i':`:'.: .1!;71.r `:
❑Geothe�al(Heating/C lingRg ) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(caIDr,hardness,soiUroektypegninsizeetc.)
Date Well Started d1 p "2� q' 0 ft. I ft- ri, - -
4.Date Well(s)Completed:01.0/'I-LA WellID#A A-�°' 3.6/,.. .5 . ft- 614 . co_n•��'f'e - ..--�
5a Well Location: Phone#: c33C- i),- ? . 6 ft. j 9 ,it.: yti d, G%I'G,n'•," "
�d✓�b'�L A • i C,t��+ .70 ft. s�.® ft, 5& 4-1 f 6' , 1tP-
Facility/Owne.rName . ' Facility ID#(if applicable) 8� ft' 3O O ft ro,'/-/ ' --- . '
�J / %�!'� 1"O i�� (�+°�re:9 �4 fL ft 4 YK j - ny i a rr. a
Physical Address,City,and Zip �iyol�+ ft. ft (� T /�✓) ''
If.(A ," i 1 Q _11'-1Z2' A`MICSfX.,:• ';';; ... ::.....1_'1:{rt.,�1....' ' ....'.-O.L•f'."r"....=saM1;:r. V1
County Parcel IdrntifrationNo.(PIN) -"" -.'"" :?'-"`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(if well field,one lat/long is sufficient) i 1 tification:-
• 3c., i .3s.�7 N kOm :r'3 54C w �. Arki. 09 . 21
6
,s'a:•ture of Certified W ontractor Date
6.Is(are)the well(s): Eermanent or OTemporary
By signing this fortn,I h-eby certify that the well(s)was(were)constructed in accordance with ft
7.Is this a repair to an existing well: ❑Yes or net 1SA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy 3
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarb section or on the back of this form. 23.Site diagram or additional well details: Vs
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 G7 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
9.Total well depth below land surface: 3 `) (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd jerent(example-3Q200'mid�Qa2 100')
440 ft 24a. For All Wells: Original fo i jto Division of Water Resources (DWR),
10.Static water Ievel below top of casing: ( ) Information Processing Unit,1617 IvfSC,Raleigh,NC 27699-1617
If water level is above casing use"+/+"
11.Borehole diameter: 6 (in.)131t Off: ,6 .v L 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)
L y I Program,1636 MSC,Raleigh,NC 27699-1636
(A j
12.Well construction method: •(� b Tom b•. 0 14 1'fI '.�
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 0
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy-to DWR,CCPCUA.
•P Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 6 Method of test: 0\l
o 9 Date Site Visited: Z$'
, 13b.Disinfection type: 7O/a hth Amount: 1 6 OZ Site Visited By: 0 C ;
Form GW-1 -__-_-- North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018