GW1--06967_Well Construction - GW1_20241119

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I ----WELL CONSTRUCTION RECORD(GW-1' For Internal Use Only:
1.Well Contractor Information:
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_ ��?�C spy A ° AC�1��e5 �9�WA'17��O11FS:�+2a.�'::; 1, � •'i'�r�' --',t:;....:,:.:..•:.. -
Well ContractorNaIIle FROM TO .•• DESCRIPTION •'
• I•-y�ir ft.
aft
d57,01A mac° ft ft
NC Well Contractor Certification Number :'1 "OIITEIZ:C ASING`(foi:,multire se.d:ieISI:O Xi1VFRAi1 s"licalilelS;';r<'=,`.;:: ...
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL _
ft ft. . in.
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CompanyName q , y „
�� / 10 "Nv f:-6" + ;ASTeIG.OR I7BING_' eutlieimarelosedliiir t:�� :`,>:%a--
2.Well Construction Permit#: •
FROM TO • DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.a UIC,Corby,State,Variance,etc.) 6 J ft if® ft ) 5 an- digs f/(
3.Well Use(check well use): A ft ft (� in.
rw13.,..,.,.. -,.,,. 73.- „.7i.C.,.&.�.,. :.:'._ ".
Water Sripply Well
PROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural• ❑Municipal/Public ft. ft in. I
Jr 1>:`
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft, ft in.
❑Industrial/Commercial ['Residential Water Supply(shared)
ir18`(5RO1IT''. c:?.; .,:a t }:� r .•> - - . .°. :t�:.
❑Irrigation . - DWells>100,000GPD FROM TO MATERIAL EMPLA.CEMENT METHOD&AMOUNT
Non-Water Supply Welly :t _� ; �i,., ... 0 ft. 3 0 ft P ON- �,i-41, T�1"6,'fe /i-,;¢,••._.
❑Monitoring D ecovery ft. ft
' Injection Well: t\LJ V I t U i. K f
ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation _ _
i Cyr )<E,-i';: . �..•:
rI9::SAND/GR91'.el-CI? 1i"ci�Ie .:,1,�.• `s:'�' .c' •er: "."..' :':.'
❑Aquifer Storage and Recovery.. •. ['Salinity BarrierPROM TO MATERIAL j1EMPLACEMENTMETHOD •
❑Aquifer Test ❑Stormwater Drainage ft ft • r
❑Experimental Technology OSubsidence Control ft. ' ft. ` '
tit •
❑Geothermal(Closed Loop) OTracer 20 DRIIJfi lOG(3ttieh'n'dritiail slieetsff.iecessar'y)<w _:'r. `;vQ:5i.
CI Geothermal(Iieafmg/Coolino Return) •❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sollhaek type,gain sue,etc)
Date Well Started/47—q, › ' 0 ft /y ft 50: / ' C. i5
4.Date Well(s)Completed:A/0 Ig „/'-�Well ID#h `]it-3Y� /S ft- 7g.,:ft rn,,e6/J �fer,e A ®�
5a.Well Location: Phone#:�f 1O"- 9S1�=G Vf q. ft. it Snip• 4.li A* very h', -(<
m+ t,.e: ', ft. ft v
�A.� Ft At • se c,': ft. ft.
Faci�litty/OwnerNam..e+� ! Facility ID#(if applicable)/ (q
! 70 'Tim L r t" A �i II C A IVY ft ft
Physical Address,City,and Zip ��" .p,.L�1• ft. ft T
J ® I:f Vl '.-'.•1?::.:Ti. lY '111.,,,-u L -.:U.,:':21f12F1l�AiiYtc:i=;>';s:::"':.1:._.,::
, ` °County " Parcel ldentificationNo.(PIN) rr�ll
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneee lat/long is sufficient) V 22.Certification:
6� iP� Ie� " l' ®!, 166., W
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6.Is(are)the well(s): ermanent or• ❑Temporary Si eofC ` ell Contractor ate
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By signing this form,I hereby cern,fy that the Well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or STo ISA NCAC 02C.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 'aphis record has been provided to the well owner.
repair under 421 remarks section or on the back ofthis 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
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construction,only I 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 9 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3( 200'and 2Q100)
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"+"0
11.Borehole diameter: (� (ia,)Bjf Off: S'°® 6 24b.For Injection Wells: •
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Copy,to DWR,Underground Injection Control(IUC)
. - Program,1636 MSC,Raleioli;NC 27699-1636
12.Well construction method: Ai r /4,7 :4� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,'cahlq direct push,etc.) - f county environmental health department of the county iyhere installed O
FOB.WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA C�
l : Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �tet"'4- Method of test: 6^/ ,Ri/
o Date Site Visited: ei—4. 'I 1 ,
- ' 13b.Disinfection type: 7O Io hit ' Amount: i� OZ Site Visited By: �,1�'�1
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Form GW-I North Carolina Department ofEnvironmeatal Quality-Division of Water Resources Revised 6-6-2018
Price: ..--7— /® _. A_ ,��f _ •.. 7 .