GW1--06905_Well Construction - GW1_20241118

.� WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
r-I.Well Contractor Information:
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9,, Well ContactorName FROM TO .'` DESCRIPTION,... ....,...• •. ...._,' .` r
j'l ft. )'g1 ft - O fi- I.5P0-i- qo CP/l'1'C/La
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NC Well Contractor Certification Number ;:15.0 /N9VdEii iilfi a i I ally AR-iINER(iLa nicableP',is;":'._. V-1
Yadkin Well Company, Inc. FROM TO DIAMETER ,TBIcl�ss j MATSRrni. —
• ft it in.
'Company Name 2 :,�•
O QV i a f cs 6"' 2- a16�INNR2i:CASING:ORUUBINC (geothermliiD..closed--16.5 =•. .. _ :af11 :5 :.--'.1-
.1 FROM TO • DIAMETER THICKNESS MA'IT:RTAI.
2.Well Construction permit#: �/�/ "�-� � .
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) •�-< ft. l(J7 ft j, k(A in. , �A-'�1. ' P1 c.
' 3.Well Use(check well use): ft. ft v I Iri �/
Water Supply Well: 9r.7:SCRi RNM•Z......_ i:Nt3.,1 •'.:1'S Li.". t_- ..._-:�eLw�'Z-L ::...:
FROM ' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑��M/unicipal/Public ft. it in.
❑Geotherm ttU�al(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) .rilITGRO:1,1f. v . - ...
❑Irrigation ❑Wells>100,000GPD FROM TO MA EMPLACEMENTMETHOD&AMO
Non-Water Supply Well: a ft' tit) ft NI 6. i i I J i_ -
OMonitoring ❑Recovery it. ft
Injection Well: ft.
❑Aquifer Recharge .❑GroundwaterRemediation • _ �..`.
i;.19::SAND%GRA.VEr'P.ACK(iia�p`phec le�;'..._,...,.'.r:.i::s;= '> . ,..-. ,
:aquifer Storage and Recovery ❑StrlinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD - •
:aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft.. ft. .
❑Geothermal(Closed Loop) ❑Tracer ;:•20:D 111,taOZOG:(attach'Q"dditiiiiirilieet3if lleessaij'ra:c<:s;";'
-under FROM• TO DESCRIPTION(color,hardness.soi/rocktype grain size,ete)
• ❑Geothermal(Heating/Cooling Return) DOther(explain
Date Well Started Io' -7..�I /y� Q ft. 1.5 ft 5®I 1
4:Date Well(s)Completed: 1U-V-) Well ID#AAG—, .�q 45 it 13 ft 4.41- j'(Y,JG "jcl f)et 5a.Well Location: Phone#:33(-J%..� �® 1-3 ft alz ft. nie11'd -6 /Atey ternet,
-
•
Faacci�iliity/OwnyyerrName L (�Faacility ID#(if applicable) f. ft _
U`Vg /�ay.Jr/kC tI 1 ek( v4 teXi te ft. ft • ^, i^ _.
Physical Address,City;and Zip r a�i a ft. it N O V 1 8 ?n 74.. .•-•.3v�e T`21w172FMA�RY[R.x,.e':".-.�. !',3:F'`'..,s a ^-7,t;i_;:._ ..1i 5:........:.5,- ro
County Parcel IdentifioationNo.(PIN) .-
13:J1..t -i0 •
5b.Latitude and longitude in degrees/minutes/seconds or derimal degrees: .l0'
(if well field,one lat/long is sufficient) 22.C tifrcation:
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6.Is(are)the well(s): L9Permanent or OTemporary
Sr ature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Vo 134 NCAC 02C.0100 or 15A 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 remarla 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-)is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
r 9.Total well depth below land surface: `� (ft') Submit this GW-1 within 30 days of well completion per the following:
1.` For multiple wells list all depths if different(example-3(4)200'and 2(n)100)
24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ® (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
If water level is above casing,use•+"
11.Borehole diameter: 6 (in.)Bjt Off: A.y•00° 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IIIC)
Program,1636 MSC,Raleigh,NC 27699-1636
11 Well construction method: Aid A Lio4-4,v/6,,, 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 G
FOR WATER SUPPLY'WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
� Permit Program, MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �� Method of test: A if"
oDate Site Visited: 7•1-it•7, \v
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13b.Disinfection type: 70� hth Amount: ) oZ Site Visited By: 003' I
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FormGW-1 - North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 S§
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