GW1--01617_Well Construction - GW1_20240313

r1ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: .1,L..C....•L. �` •
s �d 4J W 9 De(°d''‘Plt.ih°5 Yr tEIgWATT`7ANEV.P;f4:lizcZtif.:4,'...VV.; i:;le. :;.;!`•r' -
FROM TO DES TION
Well Contractor Name • aa - �,
u ,,.)ft. i,•z�. for ?rr
/('j`/''��� ft j
� � � tl � �� '�® �P•estl lt}1ti1i1NiaCiZ :�:1�.,+.Y;%3{ ^, —�
NC Well Contractor Certification Number fit it
6 �Yr�
a15:"O1TTER'GASENIOVOc multi=dried;weIIs):ORI;TNER-,(if a'"licatile)r--"1,;'c?`.');
• Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL �,
Corn fit. fit 1 in.
Company Y Name 0 ' W 'r1.6fI NER:CA RIG:OR:TUMNG: eothermal cloikniiii' -iT �.c_s:`.i R
2.Well Construction Permit#: FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) + 1 ft 34 ft 4,1st �, t Jn• F'O�eLp 'Y C
3.Well Use(cheek well use): _ fit. fit 1 i in. U
Water Supply Well: :x.7.'SCREEil.F_.F- wr": .:__i...__ _ •------Y�r: ;
FROM TO DIAMETER ,3 SLOT SIZE�V THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft a lIn. ,
❑Geothermal(Heating/Cooling Supply) KesidentialWater Supply(single) fit ft ia.
❑Industrial/Commercial DResidential Water Supply(shared) s -
❑Irrigation ❑Wells>100,000 GPI) FROM TO-b •
MATERIAL EMPLACEMENT METHOD �'' •'
Non-Water Supply Well: . 0 it
L C fit (� pp �+
DMonitoring ❑Recovery ft ft ` �19� eta t ���t°' �.�a!�•D•.:,:1y�'.;�G ,S' .
.b
Injection Well: - - ft: ft.
❑Aquifer Recharge ❑Groundwater Remediation
I.I19'SAND/GRAVEVkA•CIK(if applcable)"_` -yii." =e..=a- =;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ILACEMIIVTMETHOD •
•DAquifer Test ❑Stormwater inage ft. ft s'zl `
Dra -
❑Experimental Technology, ❑Snbsidende Control ft ft
❑Geothermal(Closed Loop)'..,. - ❑Tracer r20aDRIE'D71QG'IAG:(attachedditionaI'sheeti'ifnecessary);,:.,
❑Geothermal(fieating/Ctioliag Return), ❑Otliei(explain under#21 Reutarks) 'FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,.etc.)
Date Well Started ft 1 �. ft
#A4 y° l-
4.Date Well(s)Completed e®�p�'�o�d t' •;VYell ID p`s`�I{.'�., � fit i � ft '• �i C����.,
Sa Well Location: `Phone##:&7g,^:', :_0 9,',`' O t,z o ft. 7 2 0 ft. I IP(011.4. f t. � J d�Y .
n"-�-r t, 1. Oirt6. E,r" r L 1 ft 1tAO ft / dear, iu ,+4( (
Facility/Owner Name. :'-',: "FIP4i,t lD#•(ifapplicable), Syta! ft ,t�tI ft e.X 4-Pf� sac 4 6'fk-wA •d'1
0 ...3 l,)..r,. a� i /� ft. ft /
�t36a�34rP. d.°`I�d9 PI I" 'U r'�y`iG/1.
Physic►all Addr�esss,City,and Zap f (�'3, ,q.R 1 S ft, fit
bY ,t Vet e-t J ,0140
t V 4� I- =`RFMA.x.s .7,. .. .--�.^..--,,..--r�._.;a.---< =—_--•N .
ot..'.. .-....-. ........Jv�....Y�...�..�..:7.--._...-._.^.Y.....
County 't' ''_ "i". ', • Parcel Identification No.(PIN) "
.5b.Latitud'e and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,once platllong is sufficient) t i 22.. • cation:, tJf\ij _____1 01.4 'ez.LI.
•
6.Is(are)the well(s) ;4ermanent or OTemporary Si a of ed •"ell Contractor Date
I
By signing this fort I hereby certify that the Well(s)was(were)constructed in accordance with
7.Is this a repair,to.an existing well: DYes or Ki To ISA NCAC 02C. 100 or ISA NCAC 02C j0200 Well Construction Standards-and that a copy
If this is a repair,fill out 7rnown:well construction information and explain the nature of the of this record has been provided to the well owner. .....3
repair wider#21,remarh•'seation: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 constrction info
constrtiction,'only I`GW 1 is needed. Ini idate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 9 - (L1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ie��11 - (fit)
For multiple wells list all depths ffdifferent(example-3@200'and 2®100) Submit this GW-1 within 30 days of well completion per the following: to
10.Static water level below top of casing: a E (ft) 24a. For All Wells: Original form Ito,Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 '
11:Borehole diameter: 4 (in.)Bit Off: a U 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IIIC)
r Program,1636 MSC,Raleigh,NC 27699-1636 �--
�7 t
12.Well construction method: 41/ /r� 1 Ca 3'y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,mtasy,cable,direct push;etc.) 0 county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: to D 1
• Copy WR,CCPCUA ril
`� } Permit Program,1611 MSC,Raleigh,NC127699-1611 rip.
Yield(gpm) �I Method of test: ® ' 1 f' a �y
70% hth i. ; oZ Date Site Visited: d �-3--
. 13b.Disinfection type: Amount: Site Visited By: d"'1 I
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
Price: