GW1--06847_Well Construction - GW1_20231030

G.
• , I;L CONSTRUCTION RECORD (GW-1) =...t For Internal Use Only: ' (�
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1.Well Contractor Information:
Cr°4fs/, .J' iro % 10 c '14:,VPATEI�ZONES _ s '1??.I:;,:. . . ?; t O
Well ContraetorName / FROM TO DESCRIPTION �j QO 3S-A �Cft. xl ft 4e, 14- 6I 1�
w( 7 ft It.
NC Well Contractor Certification Number •15::oUTEFt;CASING(fdif.multi-cesed:wells)'ORLINER(ifs`licalile)T 1::"..-. !1;;
• Yadkin Well Company, Inc. FROM TO -DIAMETER THICKNESS MATERIAL.,
Company Name ty/ --� �O S 4 !
t 33G ffiIPIlVERCASING:OR:T17BING(gehtlierm`aLclosed3ooP) `' -_- . i
2.Well Construction Permit#: 0 CM!. al,a 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) .}. ' ft. D P f�-T 1 ft L .
1'I6 in• 6 -2t 'PVC._ .
3.Well Use(check well use): ft. ( ft �r tJ in. V A! v
Water Supply Well: ra..7r S.21FI T____ _.�:":.2___; �:___ .____ - - --- ..
PP ' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Pablic ft ft in.
OGeothermal(Heating/Cooling Supply) �u?�-�'dential Water Supply(single) ft ft in.
❑Industrial/Commercial 1U,R sidential Water Supply(shared) :,:18;GRO1TT"i".--,::Y --- _- !_�"_--.- --T -- -_
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETROD&AMOUNT
Non-Water SuppI Wella T- c 7..H, . ' /fie:e.y _ � ft. y ft �'e�l�el%� C�� y�v�.�,„ P
❑Monitoring . b,,,, L- •'a 1 ❑Recovery ft. ft
Injection Well: , ft. ft.
❑Aquifer Recharge O(.T 2O2'tGroundwaterRemediation .,._____.
ia19::SAND/GRAV.EEPACK'(ifapplic`able)1::-':__ , ,__�
_._____________
❑Aquifer Storage and Recove -ary z,., L�ShliIiity Barrier FROM TO - MATERIAL EMPLACEMENT METHOD ' • '
❑Aquifer Test lr:"'".�.•C,:%;ainOG ❑Storrnwater Drainage ft. \ ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 720iDRI1L1NGIAG(attach'additionalsheitiifnecesary)' .:::_T _ `_
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling etnm ❑Other(explain under#21 Remarks) ft. ft. I I ,
Date Well Started /5t ,/ � - 0 �� 4' /ee'3i >°. I/ APCISC A
4.Date Well(s)Completed . ,(9 3 Well ID# 4.1 ft --r-1 it /�vti�. /_ ���,y
5a.Well Location: Phone#:33� SO47-a%V 0+� ft /01 ft. (6. H.t7�7� 6,,..e.),
here,, j �/� --j trJ
�i/ /7 I/1.V 10.2 ft. 98I0- ft a:..•,/t f t�..l„P„ % ..ed -
Facility/Owner Name/� ) Facility ID#(if applicable) ft. ft
0J R(7 iJ Ae.1 47 ZAN #4 1, 1 vi(f ft ft •
Physical Address,CLity,edZip ft. ft.
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Cer ation:
7 w d /
-..,,,,,,,,,- .... .ii.e ,........- gs/*49-4,//a,73
6.Is(are)the well(s): i3Permanent or ❑Temporary ,e of Certified Well Contractor Date
signing this form,Ihereby cert(fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or blo 15A NCAC 02C.0100 or I Sit 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 ofthis 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 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ® 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25,p.- (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(4)200'and 2Q100')
10.Static water level below top of casing: f--)O (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: ' (in.)Bit Off:S e 9 7 t, 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 11 IV 4 Q 1161.tell 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 0
(i.e.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 e fa
CoI Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 6 lc Method of test: iJ I
�1 Date Site Visited: /3�23
13b.Disinfection type: 70% huh FFFF
Amount: sB d'� OZ Site Visited By: I :
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i ' Revised 6-6-2018