GW1--06977_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:
1.Well Contractor Information: i
�;i1Fd rift'`' ‘.0 :�.1.4':'.WiiTE1t'ZONES:•"s= ;:lc.'.r.,•.;..t't;:i. 1':s.,, .,:.,c',,.
FROM TO •' DESCRIPTION
Well Contractor le •
. r.)
3'0- ft 0 Y ft Pr eiONo �a.2 ,Ytg 9 /�7
NC Well Contractor Certification Number 15:'O113:KR rI:SINO'fflaiiiilti cal' r.ORT�TN -kirifap lica)i)ef.`•",.•7 'ti i
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in,
Company Name
1 (� (�1 i / 0 S•g1 a sC6SIN1QERCASING:OIiT[IBING;(�e'otHeimalclosedlao7`"�:-:::: , :.1----
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) 4,a f. g y ft. w o/.74-_ in pRz,,, P .
ft, it in. .3.WellUse(checkwelluse):
Water Supply Well: �37 S.CRP:F.1� ..,....ii .::,:z 'f.,:f f:1::. s.1i :-. ._="�:C --—:, :_7. '
FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in,
❑Indushial/Commercial DResidential Water Supply(shared)
. .(18MktiTYP::.9;= a?t 'ii� . -.v''1 - ,.''ai.` -•:1 .-_ ....
Obligation . ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. y ° ft. efoptilar
a 0r
❑Monitoring DRecovery J ft. r 'E ft tray 1I
Injection Well: ft. ft (�'
DAquifer Recharge • ❑Groundwater Remediation
DAquifer Storage andRecov ❑Salim Barrier i.119"SAND•/GRA 7P.i1GV(Iffpphca'Iilej`s'''''.:-'.:. �. _. •
4 g erY Salinity FROM TO MATERIAL EMPLACEMENT METHOD v1
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft I.
❑Geothermal(Closed Loop) DTracer ':20 DRIl_rhVG'T;OG'(3ttuli iadition'ilsheetiif'n'ec sa"ry')`.:!.. :;::.;L.; ;:.:: • ;'."c•
PROM❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soil/rock type grain slze et)
Date Well Started /,w-?,a',- 7 '/ C) ft 67 ft .,5�_`/ 4 smke A.•1tg liLaieRc
i' 4.Date Well(s)Completed:/2 Well ID#M4 St!g 67 it. 3'90 ft pi di Dieu
5a-Well Location:
Phone#:717,�sq_66g� ft. ft m
k�.1+L A A��r ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ��O V �j t U 2rl
CI!!14- Ga I 1 1 kJ 1Wi.,P/',,04`ivslfp�,d M ft ft -.- :,.,_, :�,. -,';?' ,... , .
Physical Address,City,and Zip _ci� / ft. s ft tt, .. o —.
County Parcel Identification No.(PIN) ce eP(,g'S OO"f 4 ipt 0Wc( I$i -h' 14�
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: . j •,
(if well field,one lat/long is sufficient) 2.2.Certification:
3 6'z' .27 ' 3O" N-5•! ° 3 S' )i° —W \ ._ tjy7'/ r
tv
Si e of C •.ed Well Contractor DateT l� � ' 1(
S
6.Is(are)the well(s):Nermanent or ❑Temporary
By signingthtsfonn,Ihereby cerujy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or *To 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy .
If this is a repair,fill out latown 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 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 G 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTITAL INSTRUCTIONS
44
9.Total well depth below land surface: 3 ®® (it
For multiple wells list all depths((different(example-3Q200'and 2©100) ) Submit this GW-1 within 30 days of well completion per the following:
S 10.St level
water level below top of casing: -75. (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I10.St level is above casing use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,)B it Off: 4,6, ' 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Il Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: K./r (a 4 i� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 6—
(i.e.auger,rotary,cable,direct push,etc.) 7 county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.F'or Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA ruk
y I Permit Program,1611 MSC,Raleigh,NC 27699-1611 '*'v
13a.Yield(gpm) 14� Method of test. �'/i es tr!
c hth Date Site Visited: '7 6•tl I.24
. 13b.Disinfection type: 70�o Amount: iFe OZ Site Visited By: / h
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources/ "t�;� Revised 6-6-2018
Price: . _ .t 9 I 1_