GW1--00548_Well Construction - GW1_20240125

--';W1 LLL:CONSTRUCTION RECORD(GW-1) : ' . . ," ,For'Internal Use Only: '. ►.1 :- , •
' r Information: -
1.Well tract oz9 �- •
(�L T i4i,WATP ZONES - - --- - - ._--
Well Conbuctor Name FROM TO DESCRIPTION, _ - '
3 c-t ?'' i :: :U�Xf fti ft. p/y -S(/T[4" /uwi AlC Yi ?
50 I i 3
NC Well Contractor Certification Number - :.15:0IITER:CiISING(flikmulti:e selVelle)ORLINER(MO'"lic`able)t�221,_='C^•
. Yadkin We11 Qornpany,,Inca ' . FROM TO DIAMETER . 'TRIMNESS 'MATERIAL
Company Name -
ft ft ID:
-q' 16 INNER}CASING:OR.TUBING:(i eothermal'cloied=lo`op77 . -- �- t
• 2.Well Construction Permit#: J FROM. TO' - DIAMETER •.THICKNESS MATERIAL (D
List all applicable well construction permits(L UI County,State,Variance,etc.) 1 a , 6q ft A.
1.25.
25, in.
P O/1 a' - 'Q v/ , (A
3.Well Use(check well use): it�9 3 t"e 1, - Gr
Water Supply Well: ' a717S SCF.PiE -_-- -- _, _
FROM TO DIAMETER ' SLOT SIZE TRIMNESS MATERIAL
' , ❑Agricultural • ❑Municipal/Public g
OGeothermal(Heating/Cooling Supply) presidential Water Supply(single). ft: .ft
❑Industriai/Commt rcial ❑Residential Water Supply(shared) 18 GTtoUT -_--- �. --- - w - ---_
❑Irrigation ❑Wells>100,000 GPD -FROM TO MATERIAL • EMPLACEMENTMETHOD&AM uNT
Non-Water Supply Well: ® ft. ft igLA
'
❑Monitoring ❑Recovery • ft. ft
Injection Well: I• hGys ,
❑Aquifer Recharge ❑Groundwater Remediation it ft. .
❑A uifer Storage and Recovery ❑Salim Barrier is19 SAND/GRAVE;PACK(if applcable)_ w:`.=.=_1• _�=---': ;-_ -
q g Salinity FROM TO-`.- MATERIAL: EMPLACEMENT METHOD. _ •
❑Aquifer Test ❑StormwaterDrainage ft '
❑Experimental Technology ❑Subsidence Control , ft. i' '•
❑Geothermal(Closed Loop) ❑Tracer ;attiaMI MIG.'I:OG'(affac'1 iitidilioia`isheets 'necessar .`, ;L cf..� :i�7..1" .-:;
FROM TO DESCRIPTION(color,hardness;s rock a site.etc)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks)
°
Date Well Started A �, y l� ft I2.O ft 5�6, .N 2 D
4.Date Well(s)Completed: 6I - ?-23 weu m# C^l 4 '�t 1 C4 ft Sjf O rr¢r<,, ., .
Sa Well Location: ..
Phone#:_ 33�e'a-2 f _w' +60, 3a'ft W)t " 1�W€j'1 tG .:y I,St44..
A •
°�f �r Ff
7'/-ipgs- �5LLv. d g30 ft ?31 ft. /v'wit, Art/f'l'�.•`f--5' 6AIy, _1.v it e-
Facility/Owner Name Facility lD#(if applicable) '.71 it d/,), -f t 1M,r.0 t ,g j Ali,t t it. - , -
•
Lok ti ,AAkiti'r° �a ?Leh ClOAlleltir ft ft i �',_ _
Physical Address,City,and Zip ft. it
County - Parcel Identification No.(PIN) FO •
CI (U A �r(r+t. I'T 0 �l L(el�f (w� �4-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �70 Ye�tol •
q
(if 22.Certification:well field,one 1at/long is sufficient) I -
XIC �5a°-'7 73- N g/ ,jai d /3Z w
6.Is(are)the well(s): ermanent or ❑Temporary Signature o Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)consauctedin accordance with
7.Is this a repair to an existing well: ❑Yes or Po 15ANCAC 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 anird 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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
chilled: I ��% 24.SUBMITTAL INSTRUCTIONS
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 ifdlferent(example-3Q200'and 2(§100)
10.Static water Ievel below top of casing: ®, • (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: e� (in.)Bit Off. S e q 70 24b.For Injection Wells:Copy to 1DWR,Underground Injection Control( JC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: y o9_1144. iayf24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc")
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I {
�1 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) "( Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611 : 4.
• 70% hth - �y�p� Date Site.Visited: eei,1e-`q°.' 3 ' #
13b.Disinfection type: Amount: „ .0 OZ Site Visited By: I ' �''•
Form G3 1 ., v North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 "�
Pric' ,1. - ° ' LJ'