GW1--06883_Well Construction - GW1_20241118

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VVES-L CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
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i.Well�,�/Contractorie/ ...•rmation:
' /' I F,141.W.STE$tZONES::;;t ;;;:;1•,-.• 'r,, . .. ;::�,:- , . 3
Well Contractor Name FROM Akit. TX.113 ft. CRIP.T10�+'o a, (
145 tf/a.J fG ft 1 iburat �A.
NC-Well Contractor Certification Number !,:1 `arfnu':CASING'(fotlmrilli:casFtiweI ;ORT tEIti(itir rai;PTS:;a':=Y..... ..
Yadkin Well Company, Inc. FROM TO nnAMET R Tfficsarss MATERIAL
ft ft in.
Company Name -. .,
riS6DNNERIC•ASINGOR:SING:(riiithecmalrlaii:Ifili'•:-:-r:.1 •:;: fl i:•-t;._:',
2.Well Construction Permit#: fig.3/ 7 FROM TO . nIAMETER TKI( Ss MATERIAL ' 1
List all applicable well constructionpermits(.e.UIC County,State,Vaianee,etc) i] ft isb ft j4 m' spj j
' 3.Well Use(check well use): _ S n,,n,fr,t �� ft 'i in ems`
b..v.5. 14 L:,;r- a ... j:ff,aai7 `'Z:..: . ;:::'e-F?:Y_ .-'4,t'rat:.-=- :3, '
Water Supply Well: _FROM TO DIAMETER' SLOTcr71r THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in. .
❑Geothermal(Heating/Cooling Supply) ssidential Water Supply(single) ft ft - in-
Dlndustrial/Commercial DResidential Water Supply(shared) ei T
i18GR0QT iLi 'x :L":. :< �: 5�: -- --
.. :.4'?'
°Irrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENTTMOPHOD&AMOUNT
Non-Water Supply Well: O ft. t at)at) ft /v„10, d nah I(860
❑Monitoring Oft. (v Recovery ft
Injection Well: .
ft. ft.
DAquifer Recharge • DGroundwater Remediation -
1::19 :t n;3 .t;=:'a.7:s`':%'. -:_..'..
DAquifer Storage and Recovery ❑Salinity Barrier FROM •TO MATERIAL EMPLACEMENT METHOD -
DAquifer Test ❑StomiwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft
. :❑Geothermal(Closed Loop) DTracer 20r1)RIt titiVGTOG(iittdc7i'saditioua llieets'if necessary):":r ,1 =~=-,,,,`-L 1
FROM TO DESCRIPTION(color,hardness,soillreek type,grain also,etc.)
❑Geothermal(Iie:uting/CooygRetum) ❑Other(explain under#21Remarl(s) s ft q7ft ®+
Date Well Started /4. -24! ,•� 1
4.Date Well(s)Completed: 1o4 'gs9 Well ID#/"t AR.'3C 4. I'T ft. 14 ft , 8 rtY -3ton41.e
5a Well Location: Phone#:.53.e "` 33. �' ft. ft
(d -1-421' ¢a yP, ab,
Facility/OwnerName Facility lD#(if applicable)
ft. ft.
NW,, It2021 G
Z 10 �:I c f.
at k-d, /1•�1 t'4. rev ft ft s ft f lr,`,,,, .. ., . 9.:
Physical Address,City,
and Zip #
. ®ee:JIl`A Gl n- . ._ ...1'=t........•._, w .. . ..14...... , w"l:.V w _ — .
County • Parcel Identification No.(PIN) -
5b:L• atitude and longitude in degrees/minutes'lseconds or decinial degrees: • v ,
(ifwell-field,orie let/long issufficient) 22.Certification: .
t C1"7 3 N g®,:3 '7 <.3( w �
1/ ',...,,:-
i ture of Certified Well =tractor Date y
9 .
Sgna
6.Is(are)the well(s): Mifermanent or OTemporary ,
� ®® By signing this form,'hereby cerh•fyihat the wells)was(were)'constructed in accordance with
7.Is this a repair to an existing well: DYes or l9No 1 SANCAC 02C.0100 or ISA NCAC 02C.0200 WeII Construction Standards and that a copy.
If this 4s a repair,fill out known well construction information and explain the nature of the of thli record has been provideed to the well owner.
,..::".,::,:.;,-7--
repair under#21 remarin section or on the back of this form. 23.Site diagram or additional well details: ' ,'-. . .
8.For Geaprobe/DPT•or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constmctionis.nfo'.':'..:`. ',. ;l
construction,only 1 GW-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: 22 (ft') Submit this GW-1 within 30 days of well completion per the follbwingi
For multiple wells list all depths if different(example-3(Q200'and 2@100')
i 24a. For All Wells: Original form to Division of Water Resources (DWR), 1"--
10.Static water level below top of casing: So (ft.) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter:
(m.)Bit Off: (.o•C.IA I, 24b•For Injection Wells: Copy to DWR,Underground Injection Control(IUC) .....-.,_
Program,1636 MSC,Raleigh;NC•27699-1636ro
12.Well construction method: Al°' d (' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the "1:'''
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY'WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
�' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) pa® Method of test: Al Po .S k`e' �r
70a/ hth Date Site Visited: g'2-` '�I �� 9�,�,m} gt "
0
• 13b.Disinfection type: Amount: , OZ' Site Visited By: �i ' '
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 8