GW1--06862_Well Construction - GW1_20231030

b WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
•
1.Well Contractor Information:
3err \ V- )ex-IrkIefs L1'4:;VATEK.ZONES c:5 .. i:.;-. w ?' 2" : Z.- nti:v'.
FROM TO DESCRIPTION
Well Contractor Namep� ,/�
J �I"� ft. a•�Oft I/ii Ie'en Too' IY�'
,2 4ft. 'OO ft lice srpitei
NC Well Contractor Certification Number '15:OIITER'CASIN'G`(for.multi-caeeddwel16j:OR•I:ZTffi2 Tiji'lf a`7rle)`- -;:';.Iv'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name �,_�
_A.:.
�/ !7�(� :16: lER:CASNG'OR;TUBING`aiithermalc7iived16110).'_.��__ ,..�
2.Well Construction Permit#: I b 1 ( L l FROM TO DIAMETER THICKNESS , MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) 4 9 ft. LI 0 ft /_*/c tn. f ,SO / 1 v
3.Well Use(check well use): ft it as in. d G?�
Water Supply Well: I:17fiSGREEiVi:s :::; _-__.•: `__:^_ --, - T-___"
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
OGeothermal(Heating/Cooling Supply) kResidential Water Supply(single) ft ft in.
❑IndustriallCommercial ❑Residential Water Supply(shared) ,- -- -------- ---- If__-------- ---- -----_----
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft/1 ft. 3 ft Moir PI� Pow 3 roQ•i g
OMonitoring - ❑Recovery // it
Injection Well: 3 16a9aeik: Cs�1 Putter 3 6>s,
. ft. ft
DAquifer Recharge . ❑Groundwater Remediation
19:SANIi/GRi1VEL;PACIe firrtPPBca7ilej i �_ . ..�--- -.- --❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft, ft
❑Experimental Technology OSubsidence Control ft. ft. •
❑Geothermal(Closed Loop) OTracer ;20 n` G+7LOG(afta`cli's`dditionSrl'slui6.1fimeessary)L_ ,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks)
Date Well Started 9 C21% 3 ,(� 0 ft 11 ft . 5,01/
• 4.Date Well(s)Completed: 1ol 2123 Well M# 4� I P 5 3 I'1 ft. 7o3 it 6 rates 11 -
. :•5a.Well Location: '�� l Phone#: mr�-S7g-93 y3 ft. ft �T , _-
' .3 co{ 1 cJ �iijvfo ft. ft =; -`
•Fa6ility/Owner Name Facility ID#(if applicable) ft. ft `�' • h" '7 f° a"'
"''. ' 5 jam' Pf �0,582r 028"607 - ft. ft OCT 3 0 2023 ' _ . .
-Physical Address,City,and Zip ft. • ft -.r,; :),•
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:
g6, $oiA82g -N $t ilbe 34Sill . W G►9 /ofajo3
• 6.Is(are)the well(s): Permanent or OTemporary Sigaa of Ce filed Well 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: ❑Yes or lIo ISA NCAC 02C.0100 or 1.5.4 NCAC 02C.0200 Well Construction Standards and that a ropy
If this is a repair,fill out mown 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 is neided. 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: 9®3 (ft) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example=3Q200'and 2Q1001 y p
50 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: • ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" - p
11.Borehole diameter 4 (in.) t a a S 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
a
12.Well construction method: Ai! l' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(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
13a.Yield(gpm) I /2
i Method of test: OjA k Permit Program,1611 MSC,Raleigh,NC 27 699-1 6 1 1
ip
Date Site Visited: — (0
13b.Disinfection type: 70% hth Amount: 3 oz Site Visited By: l _
Form ow-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
�--