GW1--06993_Well Construction - GW1_20241119

e EUU CONSTRUCTION RECORD(GW-1) For Internal Use Only: .—
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0 1.Well`Contractor Infor„mattion: p C tt
�/ O d� (s ..16 11Tf%4"1 %J )PS 11 P' at.WAtEl zo1 S..1F:; , ::-..•..;•.; • . . .. ..;ti , ,
Well ContraetarName FROM TO .•' DESCRIPTION
� ° A • ' Soft 14/'\ft 2( 1P�
�r,_ ft Jft
NC Well contractor Certification Number :15,''OUT :CASIN1,G`(f6i ulifcased:wels)`:OIY.O VEIttlfir-11 Mtil`ef i;;r:L:.-• g5
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
• ft. ft in.
Company Name er
g� ;;f6'INN}rRRCASING'OR.T'IIBING:(geotlirimal'r161ealoop)`•' �... ...
2.Well Construction Permit#: 0 2.0 Ics 2. —i-c,2- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc) *11
ft 5 ft k•/" S m ijjfL-Z 1 f V k ,�
ft. ft in. o �
3.Well Use(check well use): E17.7.7,87 0M
J
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS ^MATERIAL •
• ❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) gtesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residentil Water Supply(shared)
. iils.GItOUT s ;k_,a.. 3,: t_":ie '.. e 16;:�.r
?i. - _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -•,-,y -; b ft. 11 ft f''Ae ) e po f/c r c.A
. ❑Monitoring . - ;i,,, a. - i1IiRec very ft. ft.
Injection Well: 9LO2 ft. ft.
❑Aquifer Recharge WI) 1 ❑GroundwaterRemediation .,,:19.sAND/GRA�EYr.P,AZK(>fiPPlicab7e) '�`:". . <: `[: vim'''•'- .
❑Aquifer Storage and Recovery . - ❑SalinifyBarrier FROM TO MATERIAL EMPLACEMENT METHOD -
❑AquiferTest ll,:1,..•"' C, ❑StormwaterDrainage ft. ft
.-
❑Experimental Technology ❑Subsidence Control ft, ft .
0 Geothermal(Closed Loop) OTracer `•i20 DRIfT`QF( LOG.attaelt additi fiaT lii ti'if ne-c"xis" rc 'i `11: .':
❑Geothermal(Heating/C oliner e . )• ❑Other(explain under#21 Remarks)R FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
Date Well Started r b• v 0+ ft. MS ft Ole-e- I— .
4.Date Well(s)Completed:l 0" 2I -VI Well ID# Ai ? _ 4 6 ft. •S9 ft .rciA I k-- :W
5 •
((��a Well Location: r� Phone#:336-c(,9- Y-P 2. 6 0 ft 32? ft �,� �/J
1" `v-kldh 4Yd i ft. ft. l•
• Facility/t=er Name
/�- p ( Facility/I�D#(if applicable) ft ftSi
•
��'20 `. 9 Ck ill il 1•�If��j i In.riW55 ft ft .
Physical Address,City,and Zip 1 ft ft,
Couatli Parcel Identification No.(PIN) . ,
•
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
• (if well field,one lat/lorig is sufficient) 22 C ' cation f.// '
• - 36.. el/ °'j N S30 1/0 12 W Ni1 I ✓2 P
6.Is(are)the well(s): ❑Permanent or ❑Temporary igja e o ell Contractor Date
By signing this f m,Ihereby cent,that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l lNo ISA NCAC 0 .0100 a•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 2721 remarin 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
(add See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,on1yy GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS C.,
a
9.Total well depth below land surface: 2 eL (ft.)
For multiple wells list all depths ifd8erent(example-3QI00
'and 2®100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617 #.
If water level is above casing use"+"
,oj'�� 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)BIt Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a a D +I 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: 4d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
�'® r ermit Program,1611 MSC,Raleigh,,NC 27699-1611
•13a.Yield(gpm) Method of test: . r `i Date Site Visited: ®‘'�7i � �� ��
13b.Disinfection type: 70�o hth Amount: ¢ 6 Oz Site Visited By: 0 an ' C ��� �•©
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c,,,a,.Cm_+ -"-^—"iaDepartmentofEnvironmentalQuality-DivisionofWaterResources Revised 6-6-2018
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