GW1--05357_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:, A
CF' �,J'��► W•. i 4 wArii.zoNFS -•, • . . . _ .. . : '-.. -
�r I,Well nttactor Name FROM TO DESCRIPTION �7)
uJ✓��� ft. ft 14ye ro1C`
ft. ft ff �J 0
NC Well Contractor Certification Number 151.0111 'CASING(ftii"multi=cased'wells)ORLINER ME liable)::._:'::. . . -
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft in. rn
Company Name
• 1611NNER CASING:OR:TUBING;(geothermal closed la op)`••.'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL `\
List all applicable well construction permits(Le. 0 Cowry,State,Variance,etc) 4 1 ft. /,!,, ft. 4r/1,5 in. ('p, rl' ALIT
. 3.Well Use(check well use): ft. ft in. l
f Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal ati ooli g 5dppl0)E besidential Water Supply(single) ft ft in. r,
ti.. ❑Industrial/Corhnimia L� . i ❑Residential Water Supply(shared) V
l', .. 18.GROUT:.:: .__ _
p . ' ❑Irrigation f��L(� I R 7fl73 ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
' - H. Non-Water Supply eII _ '� 0 ft 2 2 ft, €.1.4iff-e4. r*'T y cAtt �r-. �```{lam_.
' '❑Monitoring 1 ? r,r tp PinC i'41 Vat covery ft. d ft Y
• ' Injection Well: t'QPZ‘-"
ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation
_19_:SAND/GRAVEL PACE((if applicable) -
❑Agrufer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer '20:DRECIINGI:OG(ittiinh additional sheets if necasaiPP). ..__-__ __ - _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUreek type Brain size etc.)
Date Well Started 46u.f'(23 ® ® ft. �ft so c.,I ' Le70� 56'
7,......_ •
4.Date Well(s)Completed:('jt(9/t '�3 WellID#AA--Pa-— 7(� 1 ft. gel ft. h.r ( 6, ` 41
5 WeIlLocation: Phone#:336 Ye?-7 )O ft. ^'?e,a ft e,,,
a i a 6 r t,j c•4r rkaft. 1 4 Daft, 1( 4i I 1
r f`' dtPG `' 1
Facility/Owner Name ��e Facility ID#(if applicable) ft ft J�
• kN yr% i)01 to /Ei ft. ft l�1
PhysicalAddres City,and Zip ft. ft L
X�si -y- Qe1 I "� Sf
County d Parcel Identification No.(PIN) Fv,`,f4J-g0i-gCCC) tx), 1�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degre . L/0 f— i 5 Op /(50 ?7^L-
(ifwell field,one latt/long is sufficient) 40,7 ] 2 ,Certification:
/� /� /A,— 0 ii/j
6.Is(are)the well(s): rl1'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cern;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Xto 1SA NCAC 02C.0100 or ISA 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. ,T
drilled: 1 /y 24.SUBMITTAL INSTRUCTIONSSLa
9.Total well depth below land surface: All 0-(.� 3 (ft) ltion per the following: CA
For multiple wells list all depths if different(example-3(a) 00'and 2@100') Submit this GW-1 within 30 days of well completion
10.Static water level below top of casing: 9�° (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,)Blt Off: Si C'1'S.7 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
l Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air co-/ et,-y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) r 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
e Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 Method of test: re �/
70% hth a Date Site Visited: 7--Z.9•- 2.3
13b.Disinfection type: Amount: 1 OZ Site Visited By: ice_
Form GW-1---------- --- --._.__North Carolinx,I)epartment of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price:_- �1� s
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