GW1--04416_Well Construction - GW1_20230710

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: .
P✓'F'1dt/ RI.itS u'14:,WATFaZONES i.:="DESCRIPTt _ -... ___...: , - -
FROM TO ON
Well Contractor Name i��ft. ocq,� ft ley� ' ' ,d (�J�,/j7 �'/`Gt�
Q� ' �`� • ft ft
NC Well Contractor Certification Number 1.15.OUTER WING(for`miilfi=cased.veus);ORLIPIER;0f rip 1icible);T
Yadkin Well Company, Inc. FROM TO DL4MKTER THICKNESS MATERIAL
ft. ft. in.
Company Name
cfg‘e i36iIIVNERGASINGOR TUBING(geotliermil"d6sed=loop):;,;_-__-_-__'-':r_.,_'.-
2.Well Construction Permit it: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) f ft Lf 7 ft L . in. Le Ai p- )
ft ft in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIIICiCNESs -mierERIAL
❑Agriculttual ❑Municipal/Public ft ft. i •
DGeothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft ------ft in.
❑Industrial/Commercial DResidential Water Supply(shared) ,- -
• :.18.GROpT.'
❑Iirigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V f�a ft. 26 ft i3th A Selv 11
❑Monitoring DRecovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation i:19 hANDlGRAVFi PACIC'{ifspplicabie) .:.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT.ZrriT•aID®
❑Aquifer Test ❑StomiwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control i Li-
❑Geothennal(Closed Loop) DTracer 1:20:33101:1; 4G'IAG(attactr'idditlii al'shietsif.neceiffir ',:__::_,:_-_-2_.- -
❑Geothermal(Heating/Cooling Return) CI Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sailiroek again size era)
Date Well Started b— )11^3. �j � 6 ft. 110 ft ) -i-l�'r`6 Z ! 6 r2c,c�,`
.4.Date Well(s)Completed: "J ' Well ID# �C f / ? tia ft. IA 3 ft t1ll Rollie. p
Sa Well Location:/ life.--
/� Phone#:2® 'P 7,�,-�.3�'3 �_3 f- �® ft t54-1. (�,ro i`'r rook
([3tt*�a�i 50)
re/Z� V- l �'�.C oil it Cr' .at ft. ft. `fon f- e_ _5Of I
Facility/Owner Name °' eility ID#(if applicable) (1� ft, ft , -r ' f
4 q.3 6`63 (° /ed. Leiri®i r i 0 ft. ft ;
Physical Address,City,and Zip , `.g45- ft. ft J'JI 1 9 2023
04-ez6de ( _. ,..` -
County Parcel Identification No.(PIN) (ai/'ts;'.'")`"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well EeId,one 1at/long is sufficient) 22.Certification:
C O?ig"f 33N 3/ 4"/. 7S`3'7 w Z � ;-." 6- i5 42
6.Is(are)the well(s): ermanent or ❑Temporary Signature ofCerti5e ontractor Date
l 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: DYes or J o 15A NCAC 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 remark;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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: G 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: axA
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a.10.Static water level below top of casing: 5 For All Wells: Original form to Division of Water Resources (DWR),
(ft-')
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: A (in.)Bit Off: ..775 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: k i _►^y 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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
tY Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ' � Method of test: 4,
70% hth Date Site Visited:
13b.Disinfection type: Amount: ( J Oz Site Visited By:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' - - Revised 6-6-2018
PPICe: # `f - - -
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