GW1--06959_Well Construction - GW1_20241119

I
WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information: riff
Al ' e7 s1 CO „x9'WATER:ZONES lei' :?', • lv�� FROM TO DESCRIPTION �� I
Well Contractor Name p g Sf �6 a ..
f 6 tt. t 1 w
35 CI t p 4 ` fc1.124ft ��
NC Well Contractor Certification Number 1 ;p :. (for•`m-fi=eased team):ORTA Ur�12((its"lic3ble)...:.•'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name * �� ;.�,1•6 `INTER:I::A,SING:GRTIIBEIG:(i:eotliermal dd:4 180 `.' • " . �' .
2.Well Construction Perm Y••1�it#: FROM TO . _DIAMETER TRIMNESS /h`21TEB7AL
List all applicable well construction permits(r.e.UIG Comity,State,Variance,etc) .r1 ft 33 ft 6..)St B r77 i3p;I/,s i-t..c.( r
' 3.Well Use(check well use): ft ft in.
Water Supply Well: ri
0:7 FROM ..
.FROM •aT0 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. in.
❑Geothermal(Heating/Cooling Supply); .. siident'tal Water Supply(single) ft fr
❑Industrial/Commcrcial' . IoResirient, Water Supply(shy) 0.8 GROUT
❑irrigation I(1\i ) Ct /(Wells>100,000 GPD FROM TOOK MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v • ;0 a /�
PPY ft, tl ft ��erreei 41 C4 tip peivr,i
OMonitoring _. , .7- ❑R:ecovefy • • ft V ft 1_
Injection Well: " L. .:„ . .2 . ft 1 i b .5.-)
['Aquifer Recharge ['Groundwater Remediation
i'19.SANDIGRrAVVZ5P.ACS {if5uP Ie) •..,: ..•. :Y. :..•.-
❑AquiferStoraggeandRecovery OSalinity Barrier FROM.--.'---i'o.___ _ MATERIAL Dvina rricanioD ' •
❑Aquifer Teat ❑StomrwaterDrainage ft if.-- ,
.4ei a Q
['Experimental Technology ❑Subsidence Control _ �1.:�"-In
❑Geothermal(Closed Loop) ['Tracer 20:131113,LINGI.OG(atfaclii'iditidfiilbeefiifneetssary). ...-. . . . .
['Geothermal(Heatiig/CoolingRettir) ❑Other(explain under#21Remarks) FROM TO DESCRn''IION(wlar,hardness,saNrarYtypggtninslze,elG)
f
Date Well Started a' 0 . Li ?p�] 0 ft q ft Q' I ._
4.Date Well(s)Completed: ll a..J X11 waiID A-A-0®�y-.J (fX 4 " 6ft .r� Ct rov /c...�t'�,f
3-Well Location Phone#:3f,_ou,s-i601 • . 6 f• 3f ft. t3,ea ,3 ,,:e.
ir
i;Iib`iV+ 4, k4.4-1 ?u 4i1 39 ft. ilif4 ft. -.ek. Zv i' 5 o°`.�t 4t -.3Facility/OwnerName ' Facility ID#(if applicable) L164 ft. 14o l ft iv(' y yr r 5/t„q.t{
1130 w', 1 local (�1ouf{wn Cr. Olds 41?ft 0 14 ft iu.4) 5„7 S,:.n;4
Physical Address,City,andZip D g92- 1_114 ft 71 p7C it Fr ,�-Lir, s.+C`:k
County Parcel IrlentifirationNo.(PIN) 1 r'A " 1 ,2 3 1 M.4,, 9/ .7 5,A 4,.11 e
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) . 22.Certification:
• 3 ( aOa-rg1N -t'1, -7141-1`KC,ieYwaw.,... ,re
6.Is(are)the well(s): (Permanent or ❑Temporary t A
Signature of ettified ell Connector Date
1 By signing thisfonm,Ihereby certify that the weII(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1SANCAC 02C.0700 or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and lain the nature of the . of this retard has been provided to the well owner.
repair under#21 remarks section or on the back ofthirform.
23.Site diagram or additional well details:
S.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 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: �� (fi') Submit this GW-1 within 30 days of well completion per the following:
For molVe wells list all depths if different(example-3Qa 2DDD0'and 2Q100)
10.Static water level below to of casing: £F0' (fi) 24a. For All Wells: Original form to Division of Water Resources (DWR),
i' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" /y
11.BorehoIe diameter: Cm.)Bit Off: 5 p 930 24b.For Injection•Wells:aCopy to DWR,Underground Injection Control(IUC)
-,,-II----(�- /hy�,�./ Program,1636 MSC,Raleigh,NC::27699-163 ti
12.Well construction method: air
ib�/t(J�C\I 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 0
(Le.anger,rotary,cable,direct push,etc.) county environmental health.department of the county where installed "_
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
gg n, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I 0 Method of test: I el-C.
o Date Site Visited:
13b.Disinfection type: 70�o hth Amount:6 OZ Site Visited By:
��, Pre-Construction: J i• •,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: