GW1--06989_Well Construction - GW1_20241119

., WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:
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1.Well Contractor Information: 1
..1i e Cr (,BJ ct4rkt n3 44.WATIt-zoNEs :k=�:,'.r"-.:.i ,a•.: •.- - • :;,•.T.,:,::� .. .
Well ContmetorName FROM TO ' DESCRIPTION
��ZfY )l Oft 1 I i
ft ft
NC Well Collimator Certification Number ;.14rOUTF.R,•:C't1S1NG'.(friniiill&cased'tveEs)`:OR:LINEIti(Ier licatil'e
Yadkin Well Company, Inc. FROM TO .DIAMETER THICBPII+Ss MATERIALft. ft in.
Company NamCT-
e
i A •� •� ?116eIlg1!IER C9SILIG.OR QBIATG:(entliecmi�lrlos"ed�loop)`•:•. .: ::.r« ..
2.Well Construction Permit#: IA/ FROM TO DIAMETER TBJCRNZSS _ MATERIAL
List all applicable well construction permits(i.e.UM,Comity,State,Variance,etc) 4 ( ft 1^ ft /t!AT' 1"- 5pie3 i fy c
3.Well Use(check well use): ft d ft in
Water Supply well: s:iz- RF,l ic.f f.'eve,..•: :=i_ ` ; :'_:Z_:: ..__ '%^'-= r.:_, .
FROM TO ,DIAMETER T.
SLOT SUM THICKNESS MATERIAL
❑Agricultural DnM/unicipal/Public f. ft in.
❑Geothermal(Heating/Cooling Supply) 11�Residential Water Supply(single) ft ft in
❑lndustriallCommercial ❑Residential Water Supply(shared) iai':GHOUTr. .• _ . ,._." -- - r_...
❑kigation - ._-;- ❑Wells>100,000 GPD FROM TOj MATERLIL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:.;_-`:.,'li.:. , ,....,c..: 0 ft' D S ft. I o(e Phil' FO-i,d Teel 12 143.$
❑Monitoring I7 covery ft. ft.
I+
Injection Well: N O V .t Z U e
ft ft
❑Aquifer Recharge OGroundwater Remediation ��
i/.19:SKNDIGRA F't.iMriflpplca)Ie)'v:':�_ ,".:=,_.S t== 4:;._ �.T-•=-.e:.!z. .
❑Aquifer Storage and Recovery. OSalinityBarrier FROM I To MATERIAL' EMPLACFNOENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control • ft ft '
❑Geothermal(Closed Loop) OTracer a011DRItat NGT,OG(atfiickiidaibonaTilieetiiidfn'ee safy);'.'.:° 'E 6:0. ::: : i'i
FROM TO. DESCRIPTION(color,hardness,son/rock type,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21Remarks) e� �� ft ;
Date Well Started 11111 Wi ��??�� �9 [a B-/
• 4.Date Well(s)Completed: I I 1 y 12.4 Well n#r vl1 s 3_--' 6,S- ft .146- rQft1l,;IT
5a WellL)ocation: � Phone#: 2I'.- 9141 i. 7C70 ft. " ft •
el1,3. Lo_ rdidIff` ft. ft .
Facility/OwnerName Facility 1D#(if applicable) ft ft. C
It-
r 1/ g(r eetkalwdd-r 13y'. IA C 6��,4 Nl. ft ft. • •
Physical Address,City,and Zip / '1�ta� ft. ft. r, �t-3
Physical
' J u I k e O� 2iZ1'R"F.NY'A`•12YCS;,"•,?h��� -raj;!- ':ti,f07e:a.."C_ . .;:n. _ • , ..a`?`i`'" �+(�
County ParcelldentificationNo.(PIN) '. 4 . 00
5b.Latitude and longitude in degrees/minutes/seconds or derimal degrees: ,'' .- _
. (ifwell field,one lat/long is sufficient) M.Certification: -
. 3C,2.I0tr3 N �'d, I 'i 33 )4 w
//�� lam.) ` ` [ f ( 4 -,
6.Is(are)thewell(s): BPermanent or OTemporary signal ofC ed W.ellCcutrector ,' Date
By signing this form,I hereby cert(Yj that the well(s)was(were)constructed in accordance with
7.Is this a repair to,an existing well:` ❑Yes or 12+3, ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If thiijis a repair,fill out known well construction information and explain the nature of the of this record has been provided to the 7elltowner. .
repair'tinder#21 remark section or on the back of this form.
23.Site diagram or additional well'detailr
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the lack 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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Li. "
to (ft.) Submit this GW-1 within•30 days of well completion per the following:
For'multiple wells list all depths if dyferent(example-3Qa 2000'raid 2(g100)
Static water level below top of casing: B(/ (ft.) 24a. For All Wells: Original form'to Division of Water Resources (DWR),
I10.10.waterlevel is above casing,use op" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)$It Off: G.oSG 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ail, V y 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7 Method of test: (P j 4 i t
o Date Site Visited:1i��,( -�9
. 13b.Disinfection type: 70 o lltll Amount: 1 3 Oz Site Visited By: Ad ,, 1
- I - t
_ Form GW-1 _ - ____ __North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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