GW1--06964_Well Construction - GW1_20241119

yr6 ELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
1.Well Contractor Information: (' tA
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TOs�/ W c�iI1(�t &/Pik ` (7w Dr-$ rawkavzoNestr azi I-. • .. • ® •
Well Contractor Name FROM TO: DESCRIPTION-1 S t v, ft. 5`t ff S CPlra.
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NC Well Contractor Certification Number '
:15.sOD7ER;:a3ING`(ffie:multi:cased;dreIle�`:OR'IiILIt<(ifgP"IiaiIef::;i;:''..
Yadkin Well Company, Inc. FROM TO ,DIAMETER 1 Tm EEss MATERIAL
+ 1 ft 60 ' (,(2 m'S colt-2 II P vc_
Company Name
� winbN.ER:C9S NG:OR iIl ii•w1 argeotlieTmiirCIO9Faila a.,:« -pia-Aiii;.�.•' -z ......1......12.Well Construction Permit#: 01 gf k qq Mom; FROM - TO . DIAMETER THICKNESS MATERIAL
List all applicable xull construction permits(r.e.UIC,County,State,Variance,etc.) ft ft I in-
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• 3.Well Use(check well use): ft. ft in.
Water Supply Well:
E.17iSCREEa rr`,_ ;'>: . ` •t_ ::..- -` _�� ,- -'
FROM TO D/AMETER ~SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MMJunicipal/PiLblic ft ft in
❑Geothermal(Fleating/Cooling Supply) 6 esidential Water Supply(single) ft. ft in. '
❑lndustrial/Commercial ❑Residential Water Supply(shared) sl$i"GIZOUTt" "X :' ._..__.:. .1 _"_.:1-:7-7 ''
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❑Irrigation „❑.Wells>100,000 GPD FROM TO t MATERIAL .EMPLACEMT TTMETHOD&AMOUNT
Non-Water Supply Well:.- , .';.,;.-.. .,y,: 6 ft to ft. ���'"QAt 1 GA 1 p( f0 a IA('
❑Monitoring �. c''-' -`.. ❑Recovery ft. ft '
Injection Well: N U V 1 9 (QL� ft. ft•
❑Aquifer Recharge '❑Groundwater Remediation -
j`•'19:.SANblGR ,VNi2P,AC1 (i(ip ca'Iile) .I?.'.": "s.• `F.:; :' 'e:.a`A..`:-.,.A Y .
❑Aquifer Storage and Recovery -- '❑S
- alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •IC'.❑Aquifer Test ' '._. .., v` •--- ft ft
``l7Stomrwater Drainagei •
❑Experimental Technology ❑Subsidence Control ft.• ft
OGeothermal(Closed Loop) •❑Tracer - ;;•20:0-3RXtilti iOG(attach'Saditiail'slieetfirilecessaryINT i a '.z: ?=Ci:,
❑Geothermal(Heating/Cooling Re ) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWroek type,grain size,eta)
Date Well Started 10' -11 11,'�1I% © f U ft C r� ,
4.Date Well(s)Completed:1(a'`7'a ifWell ID', ' ' U I t ft .3 0 ft i
5a.Well Location: Phone It:g/.1- 2.• )--ge.'nip3 1 ft. 4 $ ft. Q r,a-+, 1k Vt, k <
cOl1 V c9 1/ icrdan il 6 ft. 66 fL j rev0. e . 3
Facility/OwnerName - Facility ID#(if applicable) '® d 1 ft 6/,Lft ,s r i'i.t
'7 ✓ � / I- ,1,N� fL to ft. J
Physical Address,City,and Zip y0 °' ft ft •" ^��',
bit: ; I k •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) ertifiea' n: / ii�� -
• 36, ,2, 6oci - N /o 61ik�i� w fV � 7 - 2�
6.Is(are)the well(s): permanent or ❑Temporary i afore of C ed Well Contractor Date
signing A' 'onn,I hereby certr;fy that the wells)was ere)constructed in accordance with
7.Is this a repairto an existing well: ❑Yes or L lNo ISA NCAC C.0100 or ISA 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 oron the back ofthisform. `•- • .
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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.•
drilled I 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below,land surface: l V/� (ft.)
For multiple wells list all depths if different(example-3Q200'and 2©100) Submit this GW-1 within 30 days of well completion per the following:
10. below top of casing: ) 24a. For All Wells: Original form;to Division of Water Resources (DWR), o
If water Staticlevel water ab levelve casing,use op., 2 U (ft' Information Processing Unitt,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter l (irr.)Bit Off. 6.6! (. 1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) A'•
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ail. ii't... 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) l/ 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
• Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: (� �> ' �� l i�e"� 0-7 Date Site Visited:49J 2- 7-2 y
. 13b.Disinfection type: 70�o hth Amount: 3 d • OZ Site Visited By: D.i�5 sly;� ���ro�a°p��
t 8 use,
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Form OW-1 North Carolina Department oflnvironnrentai Quality-Division of Water Resources Revised 6-6-2018