GW1--06930_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: CA
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,1 Well Contractorg � Information:
Ct d Y /% t/ J .14:WA'1itr2ONES ,, :I'...•. •;: •. .,•,....• _.„..,,,,,,,•.,„.. ,. -
r).... Wy1lContractorName FROM TO ' DESCRIPTION
I_ • Abl' ft. 2, ft / d Ski-SlotLIS > i l�5 5n St5bft frc - 'l1irt- 10 ail/r,/� 3
NC Well Contractor Certification Number ;15 OU7 '"• r7.41,':O SIRG`(fermrilt cesedltveVI OR? M4clairliaia'riThMt:1-•• .. CA
Yadkin Well Company, Inc. .FROM TO - DIAMETER THICKNESS MATERIAL
ft. ft i .in.
• Company Name ~,I
Q iTG ERG•ASING'OIiR'II)3INW otliefrai cl igalii60. ;:c,'ETi,.::_,;�:.ti:-::c. .,.. / ,
2.Well Construction Permit#: S ® q®`.� L FROM TO DIAMETER ,THICF�sS MATERIAL /l (7 Jy
�,�► l� �
List all applicable well construction permits(Le VIC,County,State Variance,eta) - '� ft' &A ft bl%® m' d 1TT 6vs '-0°p,± OA r
' 3.Well Use(check well use): ft ft rn jt' i
W ter Supply Weil: rivoc REEl7c0'._'". w `. t—l-F:i':1s Fxaiil;,,�.,.�"`:l1ll ,;,,,---:---,..1.,.....:-'- -_..I /
FROM TO DIAMETER SLOT SLTE t~TBICICNESS MATERIAL _
VAgricultural :Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in
❑Industrial/Commercial - .- >DResidenhial Water Supply(shared) '18 'GR6DT ,.•. 1 `' 7 -�,
' f. :;. 4....,. 3• aiis:_F":��.. 3:&7'.7`.';'•r .. :':S.�l,, i:•-u:�.. '�i•.� `��a:u.
L'lu
❑hrigati(nl ❑Wells>100,000 GPD FROM TO �MA7�R7A7. -EMPLACEMENTMETTiOD&AMOUNT
Non-Water Supply Well: Cr (3( , }1
PPY Nu I of r!U�4 0 ft• iY ft. L/��'1 t� � �9
OMonitoring ❑Recovery. _ ft. ft.
Injection Well: -
ft. ft.
❑Aquifer Recharge C.: ..,•=DGioundwater Remediation -
i 19::SAPIDIGRAi'Y PACIE(ff(arullaib're) is.:'>,';✓.c"-.L•--=•,';"1+f.'_^e;.i„5..:_. •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMSIVTMETHOD -
❑Aquifer Test ❑Stormwater Drainage ft. ft. • .
❑Experimental Technology ❑Subsidence Control ft• ft. • •
0 Geothermal(Clos
ed Loop) ❑Tracer fia0;D12.111 NG-I:OG.(iitiieridditiiiiiirslieata`ifgeressliy-j3 MF.'.•'Sr,'-�. :C.
FROM❑Geothermal(Close g/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION(colon,hardness,soli/rock type grin also etc.)
Date Well Started 10d4 Al q� q�,M_+y� �10 ft' )4 ft. £G- 1 •
4.Date Wells)Completed: 16^-jg"2.N Well ID# Q-3 12 ei0 ft' j1) ft Sa f`.(Nit -o( .
5a Well Location: Phone#: 7d4 2.02- gS�t (w() ft. .M6 ft' i(3' t,: 11.•
r'3�, I Foy))% .
eke"' I) �,/�i �� t9 tf<IPIf •��p ft. 5o5 ft. IL W la•i41'ftref i
Facility/Owner Name g Facility D3#(if applicable) ft• ft T
/O f 2-a �al S %" /1LtJ !`' [n.�,e�O it Lf ft. ft - lPu
Physical Address,City,and Zip t� �)"'J°S4 Y . c r
y �: (PIN) Co1/44, ' ord1\ ico n boon 1 -> c-tiCit(..11 .3-
Coun Parcel Identification No. '
Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees: ram'
(if well field,one 1st/long is aufficient) 22.Certification:
A
3 ► 7 s R763: N 30, 1 119`4 W i la-10-a1
6.Is(are)the well(s): Vermanent or ❑Temporary ! edified ontractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or alb I5A NCAC 02C.0100 or 1541 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 remark section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobeiDPT 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 needed. Indicate TOTAL 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: 5—®� (ft.)
For multiple wells list all depths if different(example-3Q200'and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
%_ ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: W Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
1'1.Borehole diameter:_ G (in.)Bit O f f:...)1'9" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC:27699-1636
12.Well construction method: (� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the G
(i.e.auger,rotary,cable,direct push,e C. county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • di
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
1 V®- 4 i rj Permit Program,1611 MSC,Raleigh,NC 27699-1611 CO
13a.Yield(gpm) Method of test: it 70% hth 2 Date Site Visited: S'2-:2- �1
,,
. 13b.Disinfection type: Amount: J Oz Site Visited By: P:e r
.
Form GW-1, North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018
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