GW1--06867_Well Construction - GW1_20231030

14 CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:r
Je«7 )cAICrP�s u'34:;WATElZZONES:�....i#:ai4'`d ':,:i:. :i. L,= au=:.-N;R;, :c: i
Well Contractor Name FROM TO DESCRIPTION
ft 80e ft. t/a 6 f m M 00 K2 OM
1./5-1A it IJOVft. yz Gon ° A
NC Well Contractor Certification Number
:i5:0u CCASING'(f6'rmulti=c'a'sed'_w"ellSIORLINER(ifap livable)';aZ •'_:
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL ,
ft. ft in. ``➢
Company Name
g �j :16 INNER O QB ASING:OR.TINGf(geotliermal.clossed-loop)',='� _ - v �� t.
2.Well Construction Permit#: 3 &/ B •3 / FROM TO DIAMETER THICKNESS MATERIAL
.
List all applicable well constriction permits(Le.UIC,County,State,Variance,etc.) .J,i ft. 8I) ft /1/v in. SD R3 J Pvc P
3.Well Use(check well use): ft ft. �J in.
Water Supply Well:
a7.iSCREB.l�7r- �:_,._._T_ - _ =r4,
FROM TO DIAMETER SLOT SI7F THICKNESS MATERIAL sa
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) .83�esidential Water Supply(single) ft ft in.
❑Industrial/Cammercial ❑Residential Water Supply(shared)•
_18 GROIIT•=�:;_ = = _
❑lnigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACRMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 22 ft Mole fluj Pcwrej 12 be'S
OMonitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Agiiifer-Recharge t Y. ❑Groundwater Remediation s15SANDIGRAVFIYAGK'(ifn'p`plicable) _ .-_v _ _ :ri
_
❑Aquifer Storage and Recovery . ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD� ' '
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑'Facer :20:-DRZEING:1;OG;(atta'eli additional ssheeta'ifife`cessary)1=,; _:____ _- `
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION{Dolor,hardness sat]/rock type glair size eta)
,.,Date Well Started 9 f i4 J>'3 ' /� p U ft. ' 80 it Set'
4.Date Well(s)Completed: 9 013 3 Well INAAfp-aOt 61'0 ft. Mye3ft 6`Qt%Ile •
5aWellLocation Milk(
Phone#: ,?2 re'- 2C0 ft ft
e..l`a J�a;r LAC`J ft ft.
T
Facility/Oer Name Facility ID#(if applicable) K• ft "
i 0 C T 9 3 ZOZ3
Eden J c C- teS De Er&,ram -
'PhysicalAddress,City,andZip lv2 ' / H. ft Inn ,._ ':� :',- ,.••
�-1- .1 RRMAg7CRr`.,...��._.-..-��__ :.w�r_::•:>._'_.. ..:_�I._f.
•
3.00 at
County. Parcel Identification No.(PIN) ..
•
•Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
. (if weli field,one 1at/long is sufficient) ' 22.Certification: .
.‘e 2-4.9.32" N Rif.TY3.7.7® W +w�+� W 91,Q1�7 .
6.Is(are)the well(s):d ermanent or OTemporary Signaatt re of Certified Well Contractor Date
By signing this form,I hereby terrify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Ad 15A 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 1121 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(3W 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
l.`:• . l 0 t••I 0
"-• 9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdifferent(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: I gCI (ft) 24a. For All Wells: Original form'to Division of Water Resources (DWR),
If water level is above casing,use"+' p Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C (in.)Bit Off: S. i S? 24b.For Injection Wells:Copy to DWR,Underground Injection Control([[IC)
A Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A 1 r 24c.For Water Supply and Open-L Iop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed Z
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA i
13a.Yield(gpm) I V2 Method of test Air l� Permit Program,1611 MSC,Raleigh,Ng 27699-1611
70% hth SO Oz Date Site Visited: I . Z4 C3
. 13b.Disinfection type: Amount: Site Visited By: I C.--
i
Form --- ' • a'•'r'^•^'i^a r' t 9fEnvironmental Quality-Division of Water Resources Revised 6-6-2018 V
Pric
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