GW1--06995_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •n
..Serci w4,+k to S „Taltv'iiTER•ZONFS'_s 7 • I I . ' . 0
Well Contactor Name PROM TO .•' DESCRIPTION
o°?4'.�AZ 7sft. 2eOft 7 0 GPI
fr. it
NC Well Conactor Certification Number :;:15:OUTXR:dffiN0(foi5n`lu lirc,isd Viell7`OR7,I1,V RAits`lietile)... '•' X
Yadkin Well Company, Inc. ,PROM TO DIAMETER THICKNESS MATERIAL •I`I.
ft it In: _10
Company Name
0� ` `a ;;11Cffi ER:C9SING:OR IEfi?G:(Rd'otlida alclo's'er"3aiii •-:l•- -:'.--• .."1,• 2.Well Construction Permit#:U I 3 _/ ` e2 0 e2 9 BROM TO . MUTER Tffi(�II+SS MA.T'RIIL y�
List al applicable well construction permits(i.e.UIG Count",State,Variance,etc) 1. 1 ft. /p3 ft V�in. S Aft,3I PAC r>
' 3.Well Use(check well use): LL it in
Water Supply well: F17:'SCRE) N
BROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculhsal ❑Municipal/Public ft ft. in. ,r1
❑Geothermal(Heating/Cooling Supply).. siidential Water Supply(single) ft. Cm
❑Indostria/Commerpial . ., t.,,. i DResidential Water Supply(shared) -,ieTGROn r ; ","-_<:::'.:
aY Ntk Non W tear'Supply WeU 0\/ .) LOLLe >100,000 GPD 0 R TO MATERIAL 2 2 ft We le Pl Par a op&A 0 y 3
❑Monitoring V ❑Recovery ft. ft
q, Injecti°n WeIl: -
❑Aquifer-Rechargelr'-` •(✓•, .,. - :OGroundwaterRemediation ft ft
N ❑Aquifer Storage and Recovery ❑Salinity Barrier i`PROM /GRA' AC Crf iIA,I " .. ;` ::i::':":':i;:-; caTHOI -. . :
TO MATERIAL EidpLACEL4DIPSMETHOD ,
i . ❑Aquifer Test ❑Stomhwater Drainage ft. ft
\9 ❑Experimental Technology ❑Subsidence Control ft.. ft.
n ❑Geothermal Closed Loo ❑Tracer =-2O B 7IVG1OG affactii3ditio`n.lshietiflaeee:s
❑Geothemmal(Heating/CoolingReturn) ❑Other(explain under#21Remarks) FROM TO DESCRDl10N(colmhnrdaevsatl/raJctyp;gmtnelseete)
I Date Well Started /Of I 1 I Z 4 ft 97 ft St5Ir
4.Date Well(s)Completed: 10!I I 1214 Well ID#/44 LA°�q 1 CI 91 ft. 290 ft G rCLA 11.r,
a • SaWell Location: Phone#:: Sh�aT.L. - ft it.
99 - P�1 336.ZL1�!- ft ft
V� A f.X r;s c:/I& -s c v o,'I o a it i
1 Facility i/OwnerNam
e / Facility lD#((if applicable) ft ft.
‘A, 3 Y Fitt lI0e C A/ l/0'® V4lr.
Nt/ ft. ft •
.
Physical Address,City,and Zip ry70 ZO-7' ft' ft. r—*
S. Yaidk
County ' ParcelldentifipiionNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:' -......1
(if well field,one'at/long is sufficient) 22.Certification:
3C, n I ✓00f i N go, -77,5612. W (.A) (of iijay " i
6.Is(are)the well(s): ermanent ,or ❑Temporary Signature oiCeitiEedWeilConteselor Date
• By signing!history',Thereby certify that the weIl(s)was(were)constructed*:accordance with
7.1s this a repair to an existing well: ❑Yes or go 1SANCAC 01C.0100 or ISANCAC 010.0100 Well Construction Standards and that a copy
If this is a repair,Jill out blown well construction information and explain the nature of the of this record has beenprovlded to the well owner.
repair under 4t21 remark section or on the back ofthis 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 constriction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach arditional pages if necessary.
drilled: 9 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D90 (ft)
For multiple wells list all depths ffdi erect(example-3Q200'and 2©100 j Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of easing: .S® ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
n24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: - ___(Ir1.)13it Off. �+ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4.i.eP '0+a d'9s 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.anger,rotary,cable,direct push,etc.) / county environmental health department of the county where installed
i ' G
FOR WATER SUPPLYt�WELLS ONLY: • 24d.Far Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 1
13a Yield(gpm) f 0 Method of test: f'/ t r Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: /a s q- .2'
13b.Disinfection type: Amount: L ( OZ Site Visited By: /4,.t. i1- SU
Pre-Construction: i
Form GW_,1 v _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: -