GW1--05119_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractorr Information:
Q �x 71 pc 414.Wall RZONES ' .- '.:•:`t: �:_..:: +;;'1:`: ;;'., g,:
FROM TO DESCRIPTION
Well Contractor Name
s- a ft. 267 ft fraciwe Q' ' CftL°r-
ft, ft
NC Well Contractor Certification Number `15::OUTk:R':CASING formult.46iiiedwells'ORLYNER'ifa` licable. ._ .: " `:'. to
' _t
FROM TO DIAMETER THICKNESS MATE
Yadkin Well Company, Inc. ( ( MATERIAL ,==.---'
ft. ft. in. LA
Company Name
�7 'f16 gNitI.R CASING OR.X UBING:(geotliermal elosedlaop):..'_-_- _ :c'tap::,::
2.Well Construction Permit#: .3 f • 0 PR0 TO DIAMETER THICKNESS MATERIAL 3
List all applicable well construction permits(Le.UIC,Couniy,State,Variance,etc.) ,ft. V1,1 ft '14 in. f,_q PVC
3.Well Use(check well use): R' ft in ! 1C_
Water Supply Well: 17:SCREED' .- -- - - - _- - -- - -- - - - - -- : ;: k-
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL, _
❑Agricultural ❑Municipal/Public ft ft in.
SZ-
0 Geothermal(Heating/Cooling Supply) ,Ytesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ie::GROUT. :.- --_. - - -- -: -
❑lnigation ❑Wells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
' Non-Water Supply Well: 0 ft A3 ft f&P,dediy5 1 X/HYaccc (r .,
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
DAquifer Recharge .❑Groundwater Remediation
i7.19 SAND/GBAYEL''PACK(if applicable)'_._ . .::' r .
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD .
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑1?xperimental Technology 0 Subsidence Control ft ft.
DGeothennal(Closed Loop) ❑Tracer .20cDiult,aIGI:OG-(attacli0dditionalaheetiif,.ilecesary) -_`. _: _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness,saillroek type grarn size et)
Date Well Started 1,Q-?tm / i ft. ,� ft. �evy
4.Date Well(s)Completed: 7'3-1 Well ID# , °r��" '7* 4' 36 ft. ,s9 ft 54 ,1
Phone#: '' " -
5a.Well Location: �� ft. '2.7 it �rt �c� �f�a
t15' — (v v q,i i®i 43 ft. r�6 ft
4� �eI- /�04®f.454d Imo„ 1( 59- rani?54 —
F ty//Owner Name Facility LD#(if applicable) 7 foa ft. (� ftiltuj cc�.,1 jr ytw eye
4/i' vt ✓ rye /i 4 4.j"!.,,,Apee ft. �l ft. r kr—.r"..4"'l L9fr—1--t
Physical Address,City,and Zip / Ne a ®) ft. ft q N i..-LJ L e V =L I
A eA e- :21;RAMARRS._ _ . AO() 1 6 LO23
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S�"' " � Ultl�
(if well field,one lat/long is sufficient) 22.C tification'
11 3/i 0:cif N at Z p-'2' V g w 7 3.-�\3
turf C ed We ontractor Date
6.Is(are)the well(s): C O ermanent or OTemporary
By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or Ala ISA 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: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 O dV (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4200'and 2@100D
p 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: \A (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (r2 (in)Bit Off- S o?3 li 24b.For Injection Wells:Copy to DWR,Underground Injection Control(11JC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /.e i XI VIP 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) U 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 1
gg Permit Program,1611 MSC,Raleigh,NC 27699-1611 a
13a.Yield(gpm) d Method of test: a) �+ I
70% hth Date Site Visited: 4 -- -2
13b.Disinfection type: Amount: 67® OZ Site Visited By: V Z
r
II1-1-�_-_..-„_d-m 4" ,- North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018