GW1--03418_Well Construction - GW1_20230516

.' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inform:
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aIt_ If N-)-P C v'-e (4 a-14i;:WA1'EItZONES -, ..,
i FROM TO DESCRIPTION cl
Well Contractor Name ��ft q, ft f
D 5 �'1 ir ft if ft.
NC Well Contractor Certification Number i 1S:`OIITF1t:CASINAG'(fo'c•multi=cased:ivel1s)'.OR-I lNE {if a'"lleislin_.-._=-:."::_.";?.
Yadkin Well Company, Inc. FROM TO DIAMETERilMATERIAL _THICCICEss
+-I ft 3 7 ft 6.i gs in. 5 V M1'1 • P V t -
Company Name
:16:IlVNER CAGING'ORTUBING;G;'e"othermal:'ilbsed'Ifi'o'
2.Well Construction Permit#:WW1 P: -01(a e r u- 7-e,2 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) in/11.
3.Well Use(check well use): / .. .ft7.,,,,'".
ft _,
Water Supply Well: «SCRk17ELT ."
FROM TO DIAMETER. SLOT Ci7H THICKNESS MATERIAL �.....
❑Agricultural ❑II,�vlunicipa]/Pnblic ft .ft . / '�
❑Geothermal(Heating/Cooling Supply) CrResidential Water Supply(single) ft. m. /- ....7 C,
❑Industrial/Commercial ❑Residential Water Supply(shared) 'i18 OUr:' :,:::. --'.:`-" ---- ---.-__ Z
21_igation ❑Wells>100,000 GPD FROM TO _ MATERIAL EMPLACEMENT 1METHOD&AMOIINT
Non-Water Supply Well: P.:.: — 4? �.,) ft P 1 it. bewf..9 a Zr 1-1 y�J . e1w Plat g '.P
❑Monitorin ❑Recovery "r _,a -.- ft ft i
g
Injection Well: MAY 1. 2023 ft. ft. (�
❑Aquifer Recharge .❑GroundwaterRemedration _ . . . -----
_
19.SAND/GRAVEL P.ACIC(if if -:...___1,_Y___•...-_ " 21 ._.__r_.
❑Aquifer Storage and Recovery ❑Sa rinifaAA;CF_''n Pr `c='+"7'" 'J `'IRRoM TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Test ❑StomrwaterDraiiza ta:301..4 ft. ft.
❑ erimentalTechnology ❑Subsidence Control ..........
I. ft. / .,.—."""
0 Geothermal(Closed Loop) DTracer r20:DR7j•1;INGI:OG(attach additiai alill etsff.iieCes1 _C: t/ "
FROM TO DESCRIPTION(color,hardness,sal/rock type,grain size,etc.) 0
❑Geothermal(Heating/CoolingRetnm) ❑Other(explain under#21 Remarks)Date Well Started b ft g® ft _5 tt f tzt)t-e .f"°-""
4.Date Well(s)Completed: '" Well ID#Alie'C2-13ft. 0 9 ft &Mtn. r &Pity I fA4. ` '
Sa Well Location: Phone#:. 3(< ,'dim OQ9 / 3q ft. ® ft. it �� /IQ —
1 9
p..., �.,„,,.:,a 1- 8�S (1.� {‘,4zar 30 ft. 1 8D ft 44 f(I D1 &-rel )1„)kye z„` `f
Facility/ovVget'Name Facility ID#(if applicable) f
fl A a ft. ft.
Physical Address,City,end Zip �" g ft. ft.
l�4 10" 1:-2f REV ARRR _.,..:_ ___ _ .... ._.
County Parcel Identification No.(PIN) f f0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e•^1S Oe .i 0 —r'
•
(if well field,one las/long is sufficient) ii •-Ion:
N geb. 1 1 1 (- `3 1"
6.Is(are)the well(s): ermanent or ❑Temporary �,f+ e ofCertifie.Well Contractor Date
- 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 I iNo 15ANCAC 02C.0100 or 15A 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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobelllPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info G
construction,only l GW is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. 6
drilled: if 24.SUBMITTAL INSTRUCTIONS - • -S
9.Total well depth below land surface: �e (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2j aC3100')
I1�‘ (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617_.
If water level is above casing,use"+"
11.Borehole diameter: a (in.)Bit Off:q-•5 I ° 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
6
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ity. AD4 / 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
C
FOR WATER SUPPLY v. ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m) r'r A Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp Method of test:
a Date Site Visited: •.::—
- 13b:Disinfection type: 70�o hth Amount: So OZ Site Visited By: yea
ME i �
Form GW=1._- North_Carolina Department of Environmental Quality-Division of Watef Resources Revised 6 6 2018
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