GW1--00766_Well Construction - GW1_20240131

'• WELL,CONSTRUCTION RECORD(GW-11 For Internal Use Only:
i
Well Contractor Information:
F.54:WAITEZONES`1, .-. ._ .?,.`-- ----
•
- - FROM TO DESCRIPTION
ell Con actor Name
" @ �y 360 ft. e1 s0,o�f ft 10 cpril
NC Well Contractor Certification Number j 15.ODTER'CASING`(foimulti`cased'tve1B)'.OR'LINER`(ifa"licable)"-- '.,:
`
Yadkin Well Company, Inc. FROM TO DIAMETER _ THICKNESS MLTE .LRIA
ft. ft. 1n. �.....-
Company Name IVNER':CASING:OR'TQBING ^—
16.I (geothermalclosed:loop)' '_ __�- _::�:_.':_ "i
2.Well Construction Permit#: 1050 10 FROM TO A THICKNESS MATERIAL
List all applicable well construction permits(le.UIC,County,State,Variance,etc) j)A1 1>t. etp C�in.
3.Well Use(check well use): ft. ft. in (.A
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Allesidential Water Supply(single) ft ft. in.
❑Industiial/Commercial ❑Residential Water Su• pply(shared) •'18.GROUI ._-__ - _ -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMORINT ..)
Non-Water Supply Well: Df i 1ft' Vt. ' F,l
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge •❑Groundwater Remediation
i_19.SAND/GEtAVEL PACK(if applicable).-,-__ _ __ ___ _ -_ . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD "
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft j
❑Geothermal(Closed Loop) ❑Tracer ,20:DRICDNGLOG(attichadditiorialslieetaifnecesary). __ __ := _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO AEsc )TiON(color,hardness,soulrock type,grain sic etc.)
(H F� ® ft- t5 f t i `p e r�-t
Date Well Started ��.,-�1�-'�°
4.Date Well(s)Completed:j1-A;7 aZ 3 Welifl P `iU 345 ft lc?, ft 1,5 4'„ 'i- 8 t"
Sa.Well Location: Phone#:$ $-7 .ai,x5 ft. ft
3 // ft. ft t- , _ r"A-, -
�11 teA., I/ /4 is15 ' k, „6 i s ).
Facility/Owner Name Facility ID#(if applicable) ft. ft
gp f� _/� �yi in,' 3
fg P y e.e 6,e /..J i 01.,pleit havne 1 ft ft ter' t LU�4
Physical Address,City,and Zip N ej ft. ft In _ n
a �sDte zr:z;FAcs:,
�� `���� 5 r� � .
County*_ Parcel Identification No.(PIN) '
5b.Latitude.and longitude in degrees/minutes/seconds or decimal degrees: '
•
(if well field,one Iat/long is sufficient) 22.Certification: •
34 �'34 .d./ �D N / /3f1/39 w 1.2),...--1 3
tracto e
6.Is(are)the well(s):pPPermanent or ❑Temporary
ign ahtlEoYCertifie ell Contractor
.By signing this form,'hereby certfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an axisling,well: [ e es or hlNo d� ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construedo,fi$�formation and explain the nat&e of the of this record has been provided to the well owner.
repair under#21 remarla•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.
drilled: 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: SOD-. (ft) Submit this GW-1-within 30 days of well completion per the following:
For multiple wells list all depths if d8erent(example-3(g200'and 2©100)
1 ry 24a.For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: tl(XS (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617.
If water level is above casing,use"+"
11.Borehole diameter: 6 (in,)Bjt Off: 5, 1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: IC7 i9 7 4 1N7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed '
V..!
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 7
13a.Yield(gpm) 25 Method of test: CY 0 io'
o Date Site Visited: /a--/c.3
13b.Disinfection type: 70�c hth Amount: g Oz Site Visited By: I/'
fl r,tal Auality-Division of Water Resources Revised 6-6-2018 r
Form GW-1
Price; 4`41 -44
i