GW1--00561_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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S t'::IAi:WA.TERZONES-`--._.:: - - _' - . .-. : ' .... _. -
Well ContractorNan r1 FROM TO DESCRIPTION ;
S O�r7 SJ-r` ?�SYft. S® �r , 1 Ai.ro pma d Ae
ft. ft ' O1,-,70c 8rs,ii
NC Well Contractor Certification Namber 1:15::OUTER'CASING'(for`miilti=cased'Wills)ORIINER'(if'sp"licable), _':.7;fr.-;''-
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
'
q�01 :•16 IN1YER'CA.SINGOR•:TIIBING:(eotnermalcloled-Ioop�" 1.----'2.Well Construction Permit#: `'f FROM , TO _D7AMET Al. THIC MESS MATERIAL ,4 2.
List all applicable well construction permits(i.e.VIC Cotntiy,State,Variance,etc.) .Y I J ft /1.3 ft 4,21 j5- in. sag-a a $`+� -c
3.Well Use(check well use): L ft. ft in. r
Water Supply Well: '17:SCRT :_. --------• --- -- 1------ :` .,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in. •1
❑Industrial/Commercial ❑Residential Water Supply(shared) -_------- ---.-�.---------_- --
IB.(TROUT - -
❑lrrigation ❑Wells>100,000GPD FROM TO MATERIAL ETPLACEMErrrMETaOD6.AMouNT C)
Non-Water Supply Well: 0 ft. 4/' ft Rea.-(_J,I� ore1 t J
❑Monitoring ., ❑Recovery t(, 'ft a ft. r� irla 9-^
Injection Well: +�� dnJ.f'IQts°a� 6I C�
ft ft.
❑Aquifer Recharge .❑Groundwater Remediation •i 19 SAND/GRAVEL;PACK(if applicable)L-_---- •_ _ ... •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' -
❑AquiferTest ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer .20:DRIh TGI.OG(Attachii0diti'onifileeti"if`decceaiy):_2=- _
FROM TO DESCRIPTION(color,hardness,solllrock type,grain sire,etc)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#2.1 Remarks)
Date Well Started i�-'7- � ft 7 art S tD°/ �'Sea,l s.Mre
4.Date Well(s)Completed: /' ."J)'�3Well ID#,4,e/2-r 75'4 if 1 ft qq�' 'ft 'nee ta trer'pQ!'Yi k I4P ,/
5a.Well Location: Phone#: f/ F P- 34' ft. it ill;j Cd tor ,o fet,c*
lie
le t9 Ae t,1L Z/N,.04 ft. ft �: 7.,.'.%,-j)L fit. _11#elre7 T S�A'
Facility/Owner Name Facility
Facility ID#(if applicable) + ft. ft ;,'°" Le tom•i �.`t P °j ,f / e.k.
LOO �"!�°f eS( oj/ d?Ji� R�+ ��� iA`JF�i'1g 1t..... ft it. JQIV .ri ?Oi4
What
°y� f_ ft ft -_- .
Physical Address,City,and Zip 7h Z`If
(/_ ` fv 9,g ;21 REMARKS_..:=7::1 i n:.9.n;:iKt'L�'3 i'r::,.;trait -f,,";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) p� 22.Certification: .-
36, 0 '� 11,141N8/ `17.1O,,PC w '
6.Is(are)the well(s): ermanent or OTemporary
SJpya of C ed Well Contractor Date
r pa
signing this form,Thereby certi,f+that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o ISA 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 d 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 OW-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
i
9.Total well depth below land surface: � �d (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2©100D
.# 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: / � (fi) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
�' (in.)Bit Off: 3 92-V 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: "I` Program,1636 MSC,Raleigh,NC 27699-1636 -`- $
12.Well construction method: a r v fd1 ' - 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1.
(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) N pi" Method of test: ! Y ` - y '
o Date Site Visited: 3 a4 P k Q
13b.Disinfection type: 70�e hth Amount: 34 oz Site Visited By: %� . -i
Form GW-1 i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: i
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