GW1--06902_Well Construction - GW1_20241118

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W:rig,CONSTRUCTION RECORD (GW-11 For Internal Use Only: 1
1:,Weil Contractor Information: 1
_ m-/1-5 , ,
Mil?:WATER'ZONES' * ;u: ' ?:'<i•:
Well Contractor/N�ame �y FROM _ TO DESCRIPTION
�/�(�V // �ee 7? ft. . .r o3 ft 5 ffL5 y� %5 C 3 2 f✓/c '
NC Well Contractor Certification Number °J� ft. 3 ft So•/'1'.3 Pe 1:97/14 C.&4"'
'1570DIER:CA INNG`( EIViilii:`eased:vvelisT.ORMINEW(irP Kalil in; e-'
Yadkin Well Company, Inc. FROM TO DIAMETER THrCKPE&ss MATERIAL
Company Name �,��4 l 334•' `�ti3 - 3i,S-v ft. it in
IMINNER:CASING'ORrOHING:"W then arelOsea=3aop)C�•s::1:1 : .=. E•:.'a'
2.Well Construction Permit#: 2 140 9 FROM TO • DIAME'TR THICKNESS M4TERrnL
List all applicable well construction permits(i.e.UIC,Comity.State,Variance,eta) 'l- 1 ft 115 ft t 1/9 in-- 5 9'1.al fie j
• 3.Well Use(check well use): ft. ft in.
Water Supply Well: r�"rl.7i-SCR ;': rst,._T_z 47.;: -: Viffe vr,:Y ri h z.: ...: " 2 T .:. _
FROM TO DIAMETER SLOT SIZE TIZCKNESS MATERIAL
OAgucultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) t sidential Water Supply(single) ft ft M.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1 __-
19?GROUTt' `:` -{.r :' 1''1:W'P:; <.- iJ: 'i l;'
Oh:igation ❑Wells>100,000 GPD FROM TO . MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: ft
ft. , .1 5S
v �� c011�s y �r� r
OMonitoring ❑Recovery ft ft
Injection Well: '
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and19:SAND7GIt ;V21. : Gzk(i zpphcallijz:.:_,... ^'s. rE.i.' :i:_2__ i::' .:,,,_
q g Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD - 4 .
•
❑Aquifer Test ❑StormwateiDrainage ft' ft
❑Experimental Technology ❑Subsidence Control ft., ft
:OGeothermal(Closed Loop) OTracer J l' `e20.DR11:1TT6-LOG,'(ittiieli'a'7ditional"sbeeti'ifneeei
• FROM TO •.. DESCRIP TION(color,hardness,,satllrock type,grain size,etc.)
e
❑Geotheimal(Heating/CoolingRetom) ❑Other(explain under 421 Remarks)
Date WellStarted /0-4 .24 0 ft. Z2• ft 56I Q
4,Daie Well(s)`Completed: !6-5 2 Well ni#AAQ- 9 • �� ft. 5 4 a- ft VLt>� `a ht &41.) rc ru 4-e
3 i ct a9
5a.Well Location:
Phone#:Z. e 8°9.- C' /(( ..A ft. , ft
/% pc co
EA �• r /`Q kM� l^ve'i Si r1'► GIA ft. ft:- t. ...'': r o
Facility/Ownd Name 1 Facility lD#(if applicable) ft ft. r, 7'�1
2I-'7.i' / ,4 fett�'a.PL toi 11^fe:f ft ft NOV I �U2� . lJ
Physical Address,City,aantZip " ' WC. o1./ti(Ti l fta `p _ `.,ft Ir,f,..,..,..:. -r.r-: i-,'i
/®b.'J yt " - '21``-`-uli.M"a'Rl'Cc„ 1,1 �' -..:t. t_.._ .-1.3:. ..
County ParcelIdentfficationNo.(PIN) ' ' .J. a ._ �,
S
5b.Latitude and longitude in.degrees/minntes/seconds or decimal ci'egrees:
(if well field,one lat/long is sufficient) \\ 22;,Certifrcation: 1•
3:�° 9-2 q __3 N �'°a 3 Y i igeC 'W A' *' t �� . / .6'
`'mZ(�'
6.Is(are)the well(s): permanent or OTemporary _ , I . '-3ignature C. • ed Well Contractor Date _)
la' ' By,signing thisform,Ilrereby ceral,that thewel(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Flo 15A NCAC 02C.0100 or 15,4 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 remarks 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 GW 1 is need. 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: 11 (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3@200•and 2@I00D y P
24a. For All Wells: Original form to Division of Water Resources (DV/R),
10.Static water level below top of casing: 5,5 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use••+"
11.Borehole diameter: 6 (in.)Bit Off: 1.0 a 0 l 9' 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai t. il 4 by 24c.For 61
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 iipi���
i FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Method of test: 1 13a.Yield(gpm) 1� t)'11 p� Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: 7-/7-Z.; A
13b.Disinfection type: Amount: ID OZ Site Visited By: 0.36 I i
A Ike,, 3®Y.PJ S/,ii�so, '
Form OW-1 North Carolina Dl
partment of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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