GW1--05187_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C, 0A S ra4:,WAl�kt-ZONES?;.i:i:<:5.. -••. :..: - • " _ - .
Well Contractor Nam FROM TO DESCRIPTION
-.ft ft
ft. it
NC Well Contractor CertificationNninber ::I5:OIITERCASING(formulti:eli ed'vvelsl)'ORLINER.(ila"lidiitile):- _- n
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
,A.... ft in.
Company Name - J
?16:INNER'CASINGORTUBING(geotliermal:dosed:loop) _
2.Well Construction Permit#: F C 70R° " - . FROM TO DIAMETER THICICNESS MATERIAL M
List all applicable well construction permits(ta UIC,County State,Variance,etc.) . .1 ft ��°d ft %_ �s in e / (� a
3.Well Use(check well use): ft // ft (S� in.
V�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agucultural ❑M,//u��nicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it. in. 4
❑Industrial/Commercial DResidential Water Supply(shared) _• 18 GRODT'" - - - - - - - -.
❑lnigation ❑Wells>100,000 GPD FROM TO MATERIAL e EMPLACEMENT METHOD&AMOUNT
Non-Water SupplylWe r'-,d .t:1 t do-ft. 9 • ft ( ,ge, .,cal b .90 wl
'L.L—S Li'ft.-- as'
❑Monitoring ❑Recovery ft ft. el 0sJ t
Injection Well: d P �` �''
AUG 1 2023 ft. ft i a .i=.l
❑Aquifer Recharge El Groundwater Reniediation _
r 119.SANDIGRAVEIsPACK(if npphcalile):r'.. .. _•. _-. -
❑AquiferStoragelaOn-d,Rercoveryr.^!.2 ' .7,',1I$ a,Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test D'0— ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
DGeothermal(Closed Loop) ❑Tracer _20;DRIL7:iNGI,OG(attichadditional"slieetsif'fiee-ce`ssay) -__ - - ::
❑Geothermal(Heating/Co ling Return) 0 Other(explain under#21 Remarks) O ft. ft.TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
Date Well Started to•,90,_) �'
4.Date Well(s)Completed: l�')-‘1 P?, Well ID#OAP- 4 g® 3 ft. 2,�Oft5.0461 e i e /q )g �J
5a WellLocation:G�� -1r 47,, hone#: elk.- 243-7812.4 Me)ft. 4503.. a soy+ t/6 1.1.44 a /,,e
r$reee,t a.. C,i t v►•oe. ft. ft. '
.�o ey + igfg, Mt4v rU >, ��a � �A
�Faciliityy/Ownneer Name Facility ID#(if applicable)q ft. ft. i
/ a J //t� lye__ eii ,W C., AR Ad ft. ft.
PhysiicalAdflmss,City,and Zip d ft ft.
�914G4tat.19 ei y�. .._. :-- _..__._.�y�
County Parcel Identification No.(PIN) .i .04D ref la 0 f`k1�r � °v ed
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 3 22.Certification: f
r .,�
6.Is(are)the well(s): of ermanent or ❑Temporary Si_..,� of ,feed1j '4
ll 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: DYes or �}No 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 it formation and explain the nature of the of this record has been provided to the well owner.
repair under#11 remarks 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: Q 24.SUBMITTAL INSTRUCTIONS
62
9.Total well depth below land surface: 4 5—K/3 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q260'and IQa 100)
s° � 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: a ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24bs For Injection Wells: Copy to DWR,Underground Injection Control(IUC) G
11.Borehole diameter: 4 (in.)B it Off: ,.'-i 7program 1636 MSC,Raleigh,NO 27699-1636 °
12.Well construction method: OYy,,,' /?t 4 E7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 1
a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Method of test: e l" Permit Program,1611 MSC,Raleigh,NC 27699-1611 &Lye kr
70/o
o hth oZ y-9 Date Site Visited: 2- / Y Site Visited By: � ' J cf.-,iie_a
13b.Disinfection type: Amount: �
Fort GW-1 North Carolina Department of Environmental Q lity-Division of a er esources Revised 6-6-2018
Price:j •
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