GW1--06236_Well Construction - GW1_20230925

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'''s , LL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
J wm e.S 1;4.1\ !,14:.wA KEtzONES i :_.,7:11H:,1:'ti.:".i.% yt,_...__:Lm--LI:C i�a::,tv,:_._.,.:a .
Well Contractor Name FROM TO DESCRIPTION •
116ID - A 91 r" I 9-0ft 1t,�.,� I - ,.... cam, /L7 b�..-
NC Well Contractor Certification Number' r
315OIITER.CASING(ffir�mniti CiadfeIls)'ORL NEW if liealie ;:.::77..':. £.'.?_ •
Yadkin Well Company, Inc. FROM TO . DIAMETER). • TKuna ss MATERIAL,2Th1 'ft. ft 'in. at �• K;1.,,
Company Name _ ---r -- --;rv- .,.
g�® `x167IZNEFtGASING;OR.TIIBING((;®ot7iermal'cIosed=Ioop) 7"•.;.._.�_-• �• ;
2.Well Construction Permit#: 09`Y A • FROM TO DIAMETER i' 'TRICIOVFSS M4TFRIA�`�. t"4
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft (� ft 6.())
�'�1 3. tn• (�I�s f 2( �I,� '`s ` . •
3.Well Use(check well use): ., ft.r ft. `j i in. ✓fe Y ;` }�
0/ Water Supply Well: FROM`` TO DIAMETER SLOT S37S' ,'THICKNESS'. MATERIAL s.�
" ❑Agricultural ❑MunicipallPublic t. fti • ft in. i'. ':
esiasiitiai Water Supply R.y; i,
❑Geothermal(Heating/Cooling Supply) PP Y ft ft in:
❑Industrial/Commercial ❑Residential Water Supply(shared) • ,.-,. _
.,_ --- -------_
k FROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
❑Irrigation ❑Wells>100,C00 GPDn •
Non-Water Supply Well: .. 0 ft.• -.) ft �' 1/1 p; Cjr"tn►d7 / 3S I,4,5
DMonitoring ❑Recovery `..ft. . it.i ✓
Injection Well: it •
, A fe.. k °• -
DAquifer Recharge .❑Groundwater Remediation �, __w.-_
111.91:5'AND/GRAVISI:PACK'(if applicable)` -__:::: ._.--.,__.��-.._._-_ ti:-. _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM t TO • MATERIAL EMPLACEMENT METHOD ' •
❑A uifer Test ❑Stormwater Draire it ft. `" -
q ,� 1 ti; ' ,1;
❑Experimental Technology ❑Subsidence Contro;'i ft. it :''}'s '?,'`, .
DGeothermal(Closed Loop) ❑Tracer Zo Dlar:ENGI;OG(attach:a'ddtricualsheets3inecrsar a)=-7;
FROM TO DESCRIPTION(color,hardness,'oWroek type,groin size,etc,)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 fiemari.3) ft.' ft. - ''
Date Well Started -- 3-2 i J�- ,) l� �3 3:0.2 a , 1 �LG� �'�I�h r) °�a, ,�
4.Date Well(s)Completed:5-)S`'i Well ID# /� 6� E, ft fL,-
Phone#:q/9'_ 34`I-'7'7. 1 'ft ft::•,: , .
5a.Well Location: j / •
.�r 11 t l If et". 1-$i,(&'vtPl ft. ft. .I•:� i....X` «.z i �1L `.
Facility/Owner Name Facility ID#(if applicable) R o `+... } �a - '
ft. SEP 5 7023 . '
�1�ieB� A-t i/ (Al. T P k;l® =;,
Physical Address,City,and Zip ft ft. w -,1
;•21YRE.I.4 Xc:r'V --li�- 7_' •'.. , •Ly:xa- '1
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 1.
SC:30 9�� N �d,0 ®G w W+� ta-2f- 23 ,
6.Is(are)the well(s): Cfermanent or OTemporary Signature of Certified Well Contracto 1 Date
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By signing this form,I hereby certfythat'the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or i M(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 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 1 GW-1 js 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: 70 1 (ft.) V.
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water levelis'above basing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(I(IC)
(in.)I3it Off: 6.0 3
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well coristruction method: '
(Le,auger,rotary,cable,directpusb,etc.) �® 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
( county environmental health department of the county where installed
FOR WATER SQYPLY(W�ELLS ONLY: :24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
' 13aiYield_(gpm), . '1® A J r - Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: I ybt,+ C(R,Ae w S
70% hth ee oZ ,Date Site Visited:L-2 -2 3
13b.Disinfection type: - Amount: is l.••-` . Site Visited By: boa I i n. /y t?v'+f•ti 4
At Ca%4n41,6kf"yd."t"
• ' Form GW_l ---- --_-. North Carolina Department ofl:nvrronmental Quality Division of Water Resources Revised 6-6-2018
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