GW1--06994_Well Construction - GW1_20241119

. ALL,CONSTRUCTION RECORD (G9-11 For Internal Use Only: ,
1.Well
Contractor Information:
�j fsr4i'.WA.TIozorE5'"r.-zlii.; .,ii..', ,", • ..-i': . . . •
9 ✓ FROM TO • DESCRIPTION
Well Contracame • ) ft. JD at d-1-i5 11 GPM ClefIX
c..)`'k) —/ ft. ; ft rJ 1
NC Well Contractor Certification Number :;:13:'OU_CP.K:SSING'(for':mulii:ces6dfti•eII7':OR'W1VF ;(;i£ap'-lica`lil`e.)`r:.ss :. :. \
Yadkin Well Company, Inc. FROM TO --DIAMETER 'run:m Fss MATERIAL vJ
ft, ft. in. .`)
Company Name
I ..163INNTLR.CASING:DIVA BII apitliei mar clo'sgg=loo'TiTu.T.,ii 5: ::;:=:. 0
2.Well Constriction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,�) .Ft ft. CLC(4 a I 'Q I/1A m- Ij,9�_1
' 3.Well Use(check well use): ft lI ft �& `�� in. F� j as •
Water Supply Well: FROM TO DIAMETER SLOT SIZE yTEICKNESS MATERIAL
['Agricultural ❑MunicipalIPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) lTdential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,c3.07 BOl7T:;' .1,-'• -•- .,:i•i=zc.w4'•'•:` .;, =:_.i` .. ... =ri gtw.',1:i% `•4'(
❑Irrigation t _ ' ❑W ?100,000 GPD PROM TO MATERIAL EMYLACEMENT METHOD&AMOUNT
Non-Water Supply Well k-ti- -,* -- _ . ....,:... 0 ft ft eVt lf' -8 Vi Y /7 a4
❑Monitoring. `,I f11f 1 9 ' 4overy ft ft
Injection Well: +U ft. ft.
['Aquifer Recharge 2,-r L7Gtound9Vater Remediation s"i119SAND7GRAVr Ai '(iKii 7ica'b e - ,,:i .:- . r .511.: , x 7.,:'j'�
�,.,J.i Y.. )a.✓.e i
[Aquifer Storage and .1.,.,,:;....„,...,:::,...-1
ecovery (;',a•...2.'.DSslinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StonnwaterDrainage ft ft.
❑Experimental Technology ['Subsidence Control ft., - ft '
❑Geothermal(Closed Loop) ['Tracer '20 DRTY,TINGIAG.'(a'ifsch'a'dditi'on`al"sheets"`ifn`eciysary)°::!,::;•i.:t"`: .'-^Y::"; .74"-f:'
❑Geothermal eatin Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES TION(color,hardness,satllrock type,genie size,etc.)
' , Date Well sarted lit�s&"' .._�. ft... _ 10 ft. C •1.08 .. - -.- -.
4.Date Well(s)ComgIeted: lQ� �"' weu ID#
A�- ?7 LA ft ft
5a well Location Pone#:33C"�31 2 1 ry 2 ft. '6® ft c -1 $'- �e r c c 3
it 66-4f-SI
•
FR aA ��' �t�cko t 403., ft 1- oklY' Sr'= -i
racility/ erName Facility ID#(if applicable) ft. ft.
�/���///
Y°76- 6600,ii gc.h.col Pg., mes , (f ft. ft
•
Physical Address,City,and Zip Nr C—)0 p.. it ft. . . g'''
- /,d ki to ,:2L�2./l4t.tctWT'i z. 1.-. 'ti t-i rt ^. : 7£.c s.c:5; s k`r`a
County Parcel Identification No.(PIN) i
. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well field,one latllong is sufficient) 22.Certification:
- C,,to 11( / N gOo tO"® Frs' Wit
•
6.Is(are)the well(s): [permanent or ['TemporarySl of ed Weil ContractorDate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Ito • 15A NCAC 02C.0.100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out/mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on she back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: - 9 p� - 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: K/ (R') Submit this GW-1 within 30 days of well completion per the followings
For Multiple wells list all depths#-d erent(example-3Qa 200'and 2®100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 'J (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: (in.)B it Off:•�j'o T l ei 24b.For Injection Wells:Capita DWR,Underground Injection Control(IUC)
^ Program,1636 MSC,Raleigh,NG 27699-1636
12.Well construction method: 'r'•+ 1 V t9` 4o" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health departthentof the county where installed
•
FOR WATER SUFFIX WELLS ONLY: • i 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA e
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method oftest: l i' 'gg
70% hill a Date Site Visited: 7-469"z- off A- ,
13b• .Disinfection type: Amount: Oz Site Visited By: OI I s tra4,: tr"
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018
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Price: _�-.�_ I