GW1--06982_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1�Well Contractor Inf( JT //T0tiI1'2& li
mation:
J-0 i�' 3;1 ri4t.ws1Etezo»: � .:, -- ..
yFROM •TO DESCRIPTION
Well Contractor Name ft ay•�
C L ' d r
NC Well Contractor Certification Number " c--•
:1�`'OITTRR G-'}!SIl`IG`(fui`m-'"lir fic�sed;weI[j':OIiLINF�;Ctfap"'lt„�ef�'r:'�'�: _•.
Yadkin Well Company, Inc. _FROM To DIAMETER T ICKNESS MATERIAL
-1 ft 105 ft G.( Z S in' Vir4 Li Plic
CompanyName Ai i,0.,,n'w 3)( • 3 )/i 51. 1 16 MUMGASINGb1t;TQBINO a itlfdrularilo9eH3no't'•`; }T.':�..
2.Well Construction Permit#: 311 ct 3 ' FROM , TO . DIAMETER ; TEIC MESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc) ft ft in.
3.Well Use(check well use): ft. it in.
Water SupplyWell: a"ItaeRF Is if?-7 - r-.. ..'n'2.,'...__•! 7,1K.:"_-.:IT.-.:•: .`
FROM TO DIAMETER 'SLOT SIZE •.TRIC11'Lrss ,y.MATERIAL I..
❑Agricultural ❑Mnnicipal/Public ft. ft in. •
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in. D
❑IndustriallCommercial 0Residential Water Supply(shared) 418:, 0 .:,1. f2,,- . . , a; c:£,•,,- .a F�,4 s..�
❑Irrigation ❑Wells>100,000 GPD FROM TO -::�rpMATERIAL EMPLACEMEcITivirrHOD&AMOUNT CA,
Non-Water Supply Well: 0 ft, •-�3 f' & id g, p p C,•',p f
ii.....
❑Monitoring DRecovery ft. ft 6i
Injection Well: ft. ft.
44*
❑Aquifer Recharge ❑Groundwater Remediation
j'192:SANII)GRAVEEgi.ti•CK(iEaj e):::i' .i:;;a= ?ill.:wr:.:,*;
❑Aquifer Storage and Recovery OSalinity Barrier PROM TO MATERIAL F.NiPLACEMIEVTMETHOD -;,•I
' DAquifer Test ❑Stonnwater Drainage ft. ft.
• .h..Z,
❑Experimental Technology ❑Subsidence Control ft. ft. '
❑Geothermal(Closed Loop) ❑Tracer 20:DRTTA i'G}LOG.(attacdi idditio`nalslie`eta•id'nec"euary)'.:'l s':i s �:',':;; i t.'.`•'''•:_;r
❑Geothermal( a.
Beating/e�oh Re ) I ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(corn,hardness,sotllrock type,grata size,etc.)
Date Well Started (U—4• d '-1 U ft �j ft 0 t r'
4.Date Well(s)Completed:10',"Z. 4 Well ID# A Ao- `t t)1. A S ft' l(“ ft' r t-I,z
:.Sa.Well Location: Phone#: sit ,. I /0 O ft. ti 01 ft 5 r t..":4c..__ _ -.- _ -
2v .Qirf y1 a ©l t�.•ea- ft ft . -.._ a
April. Chi.. ;Veto •1-e�' C04-1- "A-C ,.a gtcy . F- L..`.,<> ,
Facility/Owner Name Facility ID#(if applicable f. ft F i t f s r �'' ti.
ft. ft (vU v 1 C 2lt ,
Physical Address,City and Zip 4 C.
i ft. ft I I.r �
2ta:t.Ti.wM.rfi ?,c x:_...1? i z`iizi....« 4._4'::i.S:i':; ...:, . ir 4ry
A
County . ' Parcel Identification No.(PIN)
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one 1st/long is sufficient) 2 - tificatio I l
?irk N �, 9' X w / /'o ,0.1i % I.
6.Is(are)the well(s): �ermanent or ❑Temporary S ofC a ell Contractor- Date
�/ fining this fo I hereby certtjy that the well(s)was e)consirudted m accordance with
7.Is this a repair to an existing well: DYes or l No 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 of Ibis record has been provided io the well owner.
repair wider#21 remarks 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
cnstmction,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: tq. (f') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifthf jerent(example-3Qa 20O''aand2g1000
p 6 OP
10.Static water level below top of casing: ' (ft.) 24a• For All Wells: Original form to Division of Water Resources (DWR),
limier level is above casing,use"+"
11.Borehole diameter: (in)Bit Off: • 5 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
3 a 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 Mk
12.Well construction method: tr ®s
( 24c.For Water supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,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 4''
13a.Yield(gpm) S Method of test: f~ i f 4' Permit Program,1611 MSC,Raleigh,NC 27699-1611 �Irw.e In Ay C- ,-Zy
70% hth oz Date Site Visited:3---3/ - (I o9ki'f,
. 13b.Disinfection typ e: Amount: Site Visited By: D3 1
_Form GW-1 North Carolina Department ofEnvironmentel Quality-Division of Water Resources Revised 6-6-2018
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