GW1--06893_Well Construction - GW1_20241118

r;-;• ,
'-' „„--,-------
' WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
: ..."(
1.Well Contractor ormation:f
3--Ody / Iii cxedi 11P7u 1 i r S
FR W.VIttiatZONES:'MZ1TE ' • •1 . ..
• • • 5:j<
FROM TO .•' DESCRIPTION
Wili ConNacr Name • V
LI C 4 6 - /I Iv 1 . " Z ,fk
NC Well Contractor Certification Number .E1-51•0172:1all:MS1NO(fol5EMiikiii6E-Wela.03R-TaINEllatErnialle,:_..,...1:'.', .
• Yadkin Well Company, Inc. FROM +4 TO ,DIAMETER 'ElELICRNESS MATERIAL
+ 1 ft. Iv ft 6.11i.in. Spg.02,1 plic
Company Name gremmEitagisimmartgX.GM'ffiladirclifienircin '';:-.'i••• •••!.'4.•:-.'' .. R
1.w.Ccnstraction Permit#: AeWL 2 02* 45 9 KT FROM TO • DUMMER =mess WATER:CAL
hif,••: Lir1 all applicable Well eonsiruction permits(i.e.VIC,Cow*,State,Variance,etc.) ft. ft in. 04
• ..'. • ft ' in.- .
- ''' . ••. 3.Well Use(check well use): ft
" ...• • -
t;'. • - • -- ' ' 7C1llffia • '
I •• =•'-'':-= Water Supply Well: FROM TO DIAMETER SLOT SIZE MICICKESS MATERIAL
i • '• •"• DAanitor-al DMuoicipal/Public ft, ft, in.
13Geothernial(Heating/Cooling Supply) 0bleesidential Water Supply(single)
bladostrial/Commercia1 --7, .: . 1--11.44idential Water Supply(shared) -Agraircsra. • ',.'• • •• ••• • 7f,k!.';',-;:f.r:i'':,*:. •
• Egrrigation l ;,„.1,;,, ,,-P ''''''r OWF.Ils>100,000 GPD FROM TO ' MATERIAL ENTIACEMENT METHOD&ANL-OUNT.
Non,Water Supply Well: '.4 S /.t.)LLV 0 ft. 1"3 ft. iq CIO V.r
ElMonitoting • ‘40\I 1 ORecovtay,1., ft.
Injection Well:
ClAquiferRecharge ,J-.;.:.-•• ci.;,:..„;..PGraunriwater Remediation ,
i(19.SAM157i3ltiMEO:Plitircifigilri) .•::.v•-.1:•';••,':::,•••:::11•4';.111.Zv-1.'4.-::::::..! :-.-•''.
, • ' : . OAquifer Storage andRecovery ElSalinity Barrier FROM TO MAMMAL EMELAcENEENTIorman ' •
ft.
OAquiTer Test OStomiwater-Drainage
clExpeadmeatal Technology 0Subsidence Control ft. ft.
' . .
, .
''''• EIGeothermal(Closed Loop) Effracer f-v.D.):1100.filliGIOG(itfiel' f.necessary).'...'...f...1.,i,:::,- •::::.••.-•
. ,
, • MOM TO DESCKETION Naar,haziness,saillro dr type,grain she,' ate-)
Eldedthennal(Heating/coo- ElOther(explain under#23.Remarks)
Date Well Started 11"a - o ft 1 0 ft '-cli,
..,
4:Date Well(s)Completed:I I-6 d-ILA wenn# .44 i i ft- 7o '11.;,' ...it
. .,... .
. -.,,.
Phone#:33( - 110,3 i 7 to ft. .ft. .i ibe. -,7 a IA6,jfq
. Sa.Well Location:
'1;1 Sol'n tt-ie. "fi eaf491 /1,241 9 l ft. a V i.' i i r:eh'dt 11 -
--:.,..
Facility/Ownerblay.te', Facility Batt(If applicable) 1 0 " 64 2.1t. Jr1 .•.ke; - , .. :.
,
el ,,. , , ..\C ft.
,(7-.2_s>. ,p•-•_,verckaio- (ZS ri Pi At;le t<' ' ,- .'4.,..%
-....:-.-:,,.... .
-physical'Arldiess,City,andrip PI OLH ft
'06')
'' .I;1kialics:;• ','•' i'i''1'::'-•:!*'•)1::""1,1 ".•''-'':•:•"V;*V "1:':•:::•';"ir':-,•-:'--:•;-':::f' se.1
ry ...,)i
covAty Parcel IdentificatianNo,(PR
• ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fteld,one fat/long is sufficient) 2 ertificaii : . : C''
.1519 '.9b ) 0 -19 N T •46ti Ole 1S2-
••• •-11.'
. ..•
Well ';.- , •. „., '
6.Is(are)the well(s): Mermanent or LlTe:mporary of ed Contraebai ate
signinvhis form,Merely ceraihatthoivell(s)Was(verie)coristructedin accordance with
7.1s this a repair to an Existing well: ElYes or ao 1.5A NCAC 02C.0100 or MI NOW a?p..00ti Well COnstruction binder&and that a copy
If this is a repair,jill out knownwell construction information and explain the nature of the of this record has been provided to the*ell owner.
. .
repair under4121 remark-section or on the back ofthis form.
23.Site diagram or additional Well'ilatalls: • ,
You may use the back of this paleto proVide additional well censtrueden ktb
• S.For Geoprobe/Drr or Closed-Loop Geothermal Wells having the same
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.Indicate TOTAL NUMBER.of wells
drilled: ' / t
24.strawcammmrsTRuclioNs
9.Totalwell depth below land surface: 6 ut 2 this GW-1 within 30 days of well completion per the followings
For midst:de-wells list all depths Vdiffereni*ample-3(4)200' ... .62 OOD (ft.) Submit
..:".
, 24a.For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: - (ft) InformationYrocessing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
6 11.Borehole diameter: _ an.)Bit Off: • -0 5 24b.For Injection-Wells:Co DW
py to' 4,Underground Injection Control(IUC)
___. . . Program,1636'MSC,Raleigh,NC,2'7699-1636
. 1
12.Well construction method:Arit if 00 -.9#7.7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.anger.rotary,cable,direct push,etc.) county environmental health department of the county where installed •:,,,,
FOR WATER Sul'PLY WELLS ONLY: - • c''
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA• ""....„
13a.Yield(gpm) .., 7 g -- „ -,..•
Method of test: Ut Permit Program,1611 MSC,Raleigh,NC 27699-1611
i rZ)
' —t •
Date Site Visited: ii-y-zy
70% hth 1 OZ
13b.Disinfection type: Amount I .• Site Visited By: ina7S;1 ..I\
.,
Pre-Construction:
..., orra.GW-1 North Carolina Department of Environmental Quality-Division af Water Resources Revised 6-6-2018
—••-• ''- I
- ,
. . ,
. . .
, . , ...