GW1--00543_Well Construction - GW1_20240125

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:CONSTRUCTION RECORD(GW-11 For Internal Use Only:
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tractor Information:
If 1e Information: `�-
) 4�O B �4Al]iv-
S J r OA WATER.ZONES":,:;,;.- ': '`: .. - - -- ,:_L. 'r
Well Contra° Name FRo TO T DESCRIPTION
m
5 6 6 sA 4 .7 y y
ft '7 ft 90(3,it" y1�1
NC Well Contractor Certification Number -
15 OTTPER.CASING'(for'iuiilti=cssed_:wells)ORLftsIER(ifa" hc`able):�_,:v'. ,'„,.•'->..:
Yadkin Well Company, Inc. -FROM TO _ DIAMETER THICKNESS MATERIAL
ft ft. ' in.
P Y
Coin an Name '16.TERGISIT!1GOR-1.1.1iINGrgeothermal`dosed-lode)•-'-.•`_; __�_��:;: ,ii.i' `
2.Well Construction Permit#: FROm TO . DIAMETER THICKNESS MATERIAL 01��
List all applicable well construction permits�.e.UIC,County,State,Variance,etc.) ,�l R' '} '"l 4g..f t . 7 J ©I I® (A Ii/(t,, Z v, r
3.Well Use(check well use): f t' — f t in _ 7'
Water Supply Well: C 11--.1.:22:ti u ____---- - --7- — ---IL:
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public g. ft in. lte
,I
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
❑Industiial/Commercial ❑Residential Water Supply(shared) 18'mow _•_- - �•.____ _.- -- --- _.
❑Irrigation ❑Welts>100,000 GPD FROM To MATERIAL ErffLACEMENT METHOD&AMOUNr
Non-Water Supply Well: © ft. To ft k+1,0 4.4. Q r- -d rt lrS it G,t.G S
❑Monitoring ❑Recovery - ft., ft. / '-`
Injection Well: ft. ,,
❑Aquifer Recharge .❑Groundwater Remediation -• 54
119.SANDIGRAVEIrPAC&(if applicable):_ -_ _ -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
, ❑Aquifer Test DStormwaterDrainage ft. ft. S",
❑Experimental Technology OSubsidence Control ft. ft a
❑Geothermal(Closed Loop) ❑Tracer -20.DBIti >IGLOG(uttaclad'dilioua'Lalats"'if lecesraiy)l'_ -- -.` - --. - '
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrack type,grain size,etc.) '
Date Well Started 12-2 $ - Z i /� 0 ft I I 0 ft. Sb 1,1
4.Date Well(s)Completed:I Z-7-9'2-; Well JD#AA P— 5,' i) I ft l 10 ft 1..)t o T i ,e d Q ock
5a Well Location: Phone#:33(y--4172-71S,r i';() ft. V c4tf. braid c Jjre...,U
�ta #14i4,v� �0'nSan I Li/ ft i ft.4 7 .faya► i-o.r4 9rb.e.�k
Facility/Owner Name Facility ID#(if applicable) 41 S ft h ?7 ft (4.4r& l'oF4- 3r Nr.ii-(,
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Physical Address,City,and Zip A G Car r ft. ft'oL D 21.REMARKS ._ _.-___.._._.. T? $- ', i i i'..:. a'`l '.,.` '
County fr I , Parcel Identification No.(PIN)
JAN252024
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 ertification: r ����
Ca li a' P tr`/N / ° C4 ' / `" W /i G:4e e' 1 2 -74 -2-3
6.Is(are)the well(s):>?ermanent or OTemporary hire of C ed Well Contractor Date
By signing t 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 To ISA NCA 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well constructions 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 Geo robelDPT or Closed Loo Geothermal Wells Navin the same You may use the back of this page to provide additional well construction info
construction,only I 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 wen depth below land surface: 1 7 .7 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(200'and 2Q100)
7 24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: (, ' ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter W (ia)B It Off: Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: (7 P I'd.' 1 A 7 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 106 # Method of test:_Psi A I,r r' VT I ,Lt.,, -
Date Site Visited: i I • l - S 1---PP. 13b.Disinfection type: 7d�e hth. Amount: i 2... OZ Site Visited By: lilt, .p. 1,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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