GW1--06239_Well Construction - GW1_20230925

i
CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.well Contractor Inf rmation• F
1/ 70" 4.WATERZONES_:--:i.__�— .-_:Z__:.. �._2_,_-__:_. ._. I.
FROM TO DESCRIPTION
Well Con c'torN/ame ft- ft /f/je '}S pot05G?, 0,n
9�'�5r ft ft ! + IV
V
NC Well Con for Certific ation Number _15:.OUTER CASING."(for'multi case'd'svells)ORII RR(lap plidhbie)`--__._- �,
Yadkin Well Company, Inc. FROM TO DIAMETER _ THICKNESS 1 MATERIAL
ft. ft. in.
Company Name a6IINNER CASING:OR:TIIBING:'e ithermal dared lo'o 3
2.Well Construction Permit#: LI'ec-G q v.) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(I.e.UlG County,State,Variance,etc.) f 1 ft. I'1 f�/ft. `.-U m 'pi$ /ohi�t(I
ft. _` ft. in. C/"
3.Well Use(check well use): _
Water Supply Well: E17z;StEi-FA 7 —---- __. _ = -----` _:•_
PP YFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL, ref
❑Agncnitural ❑MunicipaliPablic ft ft in.
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft ft. In. 0
❑Industrial/Conrmercial ❑Residential Water Supply(shared) isi GROUT. ."....___>____-_ ___ - �- _ .-: --.
['Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT •
Non-Water Supply Well: ° ft 30 ft. j f ch s gram,/ a
❑Monitoring ❑Recovery ft. ft 4J '^ C/ 0
Injection Well: ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation _"
i,„19-SAND/GRAVKLPACK'Ci faPPHcable):.: -""�._.��_2 _R--- _,.�
:Aquifer Storage and Recovery ❑SalinityBarrier FROM To MATERIAL EMPLACEMENT METHOD. ' . &...
['Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Te hnology OSubsidence Control ft. ft
❑Geothermal(Closed Loop) ['Tracer ,20:DR= +1GI:OG;(attacli t-Millinalsheefiifiiec`wsary) _ ________--
FROM To DESCRIPTION(color,Hardness,soil/rock type,grain size,etc.)
(Heating/Cooling Return) 0Other(explain under#21 Remarks)
OGeothermal
Date Well Started $-,)-.2,3 ,,,,nn ,��yy (9 ft. (o ft. '3 i
4.Date Well(s)Completed: e'" 'oV Well ID IAA P�, it f'! ft 60- - /41-"ie rocK
5a.Weil Location: Phone#: 3 36- /1-39�.'7 5 1• ft. /07 ft. CSC
/ �s a (� ia'�ttag, a...9 esi 'Q( ftZ33 ft. � f �- E
Umdat /h. (tap,' may, S �t
TyIOwner Name 1 ' �1�en ' Facility ID#(if applicable) �j D ��0 , I N► ��i t\
176 Oe_P.r Dr- Pao' l rf^NC/ a 110 it W% ft See}. i,�h f 3r..r(YJ r
•
Physical Address,City,and Zip are ft. ft J'
IA) k _21,REMA_RKS::� _�-R—:.( ;:`-.-..,-�4:/.L.,;—1.:... _":". _, 4.
7, v
County Parcel Identification No.(PIN) V4'
5b n
.Latitude and longitude in degrees/min or decimal degrees: S E P r 2023 .�
(if well
fir / �1ll'geld,onelatllongissufficient) 22.Certification:.," it?.it?3tt+1 orr , �3i�I
•
y
6.Is(are)the well(s): Igfermanent or ❑Temporary tun o ed Well Contractor Date
l/ By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance with F
7.Is this a repair to an existing well: ❑Yes or liti4 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#2l 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 GWJ--l(js needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTRTAL INSTRUCTIONS
2�
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q200)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 10 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"11.Borehole diameter: 6 (in.)Blt Off: b 6 a'' 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
-}�� Program, MSC,Raleigh,NC 27699-1636 s 6
12.Well construction method: rd r" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the Uzi
(Le.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 ii Permit Program,1611 MSC,Raleigh,NC 27699-1611
r
13a.Yield(gpm) S Method of test: 1
Date Site Visited: g ,o T2-i
13b.Disinfection type: 70 o�0 hth Amount: hO OZ Site Visited By:
Form OW-1 . Notth_Caralioa l)s°ad Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: t
l a