GW1--03920_Well Construction - GW1_20230612

ELL CONSTRUCTION RECORD(GW=11 For Internal Use Only:
1.Well Contractor Informmation: _
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_ Lg ' WATER'ZON ES_
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Well Contractor f TVA/
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NC Well Contractor Certification Number JUN d'. 15.OUTER'CTU forinDL4,METER lls OTHICK E ifui'1iMAT _
Yadkin Well Company,,InC. FROM TO DLL�lETER THICKNESS .- MATERIAL i
s n ft. iL in. ;
Conipany.Name dlk+G, i 16:INNERCA. G:ORTUBING• eotfiermalclosedloa' _
0� ^7 FRO ti TO DIAMETER, THICKNESS' '.MATERIAL
2.We11 Construction Permih#I: 0 1 tt. ft is
List all applicable a el1'constnru ion permits fl.e.UIC,County,State,Variance,etc.) �'
ft. ft. in.
3.Well Use(check welt use):
17.SCREEN
Water Supply'Well: FROM I TO ER SLOT SIZE THICKNESS YlATFL '
[]Agricultural, ❑Municipal/Public ft ft. In
��rr .
❑Geothermal'(Heating/Cooling Supply) 0Kesidential Water Supply(single) ft, ft. in
^ ❑Industrial/Commercial. ❑Residential Water Supply(shared) 19:GROUT
❑W , FRONT TO MATERIAL. [a� EMPLA NT CEME
e11S>100 METHOD&AMOUNT.
❑liri ation 000.GPD {1i j p' ($rL�
V
Non-Water Supply Wene �r
❑Monitoring DRecovery ft.
Injection Well: ft. 1.ft.
❑Aquifer Recharge ❑Groundwater Remediation .19.S9ND/GRAVEL PACK if a licabl'c` EMENT 7
❑Aquifer Storage:aud,Reeovery ❑Salinity Barrier FRoat To bIATERIAI EMPLAC METHOD
❑Aquifer Test OStormwater Drainage'
ft. it:
❑Subsidence Control fie ft.
[7FxperimentalTechnolggy
❑Geothermal(Closed Loop) ❑Tracer 20..DRIL'LING:LOG ttach'additionalslieets if necess
FROM TOM- DII'TION color,hardness saNrock e n sGr,etc.) a
❑Geothermal.(Heating/Coolin Return) ❑Other(explain under#21,Remarks) ® ft.Date Well Started'S�IY' —4.Date Well(s)Completed:`sue_Well IDii 1' 1.9 ft .. rC - I
5a.Well Location: Phone# �O', _ ��:' � ,9 ft �.6 tr
d�� f f 4C ,
f4 ft. I i
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Eab�hty/Owner Name j . 43
Facility ID/#-(ifapplicable), fi `'fjy,t C
ftt..
ft:
Physical Address,City;and Zip _-
05 for
County Parcel Identification No.(PIN) _
Sb Latitude and longitude in degrees/minutes/seconds or decimal degrees: m
(if well field,one lat/long is sufficient)' 22.Certification":
®r: N, e� i .- mob Wr` �
Signature of Certified Well Contractor Dot°
6.Is(are)the well(s)ermanent or" ❑Temporary
By signnng riffs form;I herebpcertify that the weU(s)was(were).coistrucred in accordance with
7.Is this a repair•to an existing well: ❑Yes or L�tV o, ISA NCAC 01C.0100 or]SA NCAC 62C.0200 Iva Construction Standards and drat a copy
If this i$a repair,fill out knoum well construction information and explain iheaature of the of this record has been provided to the well owner.
4
repair under#21 remarks section or on the 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 I
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over in Remarks Box):You may also attach-additional pages if necessary.
construction,only 1 GyJ-1 is needed. Indicate TOTAL NUMBER of wells
drilled: f( 24.SUBMITTAL INSTRUCTIONS
Ql •
9 Xota1-well depth Below land surface: / (fG) Submit this 6W-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(arample-303,200'and 2Q1001
24a. For All Wells: Original form'to Division of,Water Resources (DWR), '
10:,Static water level below top of casing: S pad (ft.) Information Wocessing Unit,1617 MSC,Raleigh,NC 276994617
If water level is above casing,use-+" '
24b.ForIn9ection.Wells:COPY to DWR,Underground Injection Control(IUC)
11.Borehole diarneter: (in.) v Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction.method: /�I �O�O-� 1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy t°the
(i.e:auger;rotary,cable;direct push,etc.) county environmental health department of the county where installed j
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over uuu m0 GPD:Copy to DWR,CCPCUA j
l [� Permit Progtam,.1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm)' `
j ���l Method of test: . 81 is
t
70%hth Oz
13b.Disinfection type - Amount:
f%ifc�— %3-
ra..w nmental'Quality-Division of Waterltesourcesr - Revised16-6-2018 i
Form GW-1
Price: I