GW1--01689_Well Construction - GW1_20240315

' WELL CONSTRUCTION RECORD (GW-'1) For Internal Use Only: I
,
1.Wel(Contraactor Information: j
p/9v�1 p�� I 11
9 • C G Ali t14:WATE$ZONESSI iiiCi�.` {.'::z- "' ?;". �� : .,s...W...
Well Contractor Name - FROM TO J DESCRIPTION 7 yr/ {�
s ��? ` l}- I�i l tfft L i I
NC Well Contractor Certification Number S�''tl
;15::OUTER'CA 91NG(fri'rmulti=e�Sed;welTs7':ORLTNEIi(ifap'livable)i,.-="� -`.S;:t;:
Yadkin Well Company, Inc. FROM TO DIAMETER; THICKNESS 1 MnTERrtL
ft. ft • in.
Company Name
s s '?16 NNERIGr1SING:ORTUBING:(geotliermal elos3=1°op) �=T=:::
2.Well Construction Permit#: `^� FROM TO DIAMETER' _ THICKNESS MA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) + i ft 13 Bl it, 69 �12 ;in-;in- J o 4(
3.Well Use(check well use): ft ( ft V lin
Water Supply Well: :1.7rSC-Rtais.,=-". _____ ��r, _...:.._'_.__' __ ---
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL^�.
❑Agricultural ❑Municipal/Public ft ft in ! '
OGeothermal(Heating/Cooling Supply) X2esidential Water Supply(single) ft ft in.'
❑Industriai/Commercial ❑Residential Water Supply(shared) 18:.GROUT,-- -�-'T:Tr z,_ "-��_—: -1 V
❑luigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AVOUNT
Non-Water Supply Well: 0 ft PI f t• 92/I i it Ch v S p04,,,y/
OMonitoring ❑Recovery ft ft. I
Injection Well: �l �O�S
• ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation I
t 19 2111Dita ANY P.CECaf ippficali10 „- _-"___:, -_-.. . ,,
❑Aquifer Storage and Recovery ❑Satin ity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD - •
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Tffthnology ❑Subsidence Control ft. ft 1
❑Geothermal(Closed Loop) OTracer _10iDRIl*:11YGT:oG'(a`ttaclfs`I[ditioaal;sheetiifi a es-Eiry)=` 7- �
�` FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) '
OGeothermal(Heating/Cooling Return)_ ❑Other(explain under#21 Remarks) •ft. ft. a �- ' •
Date Well Started —i—� �f Cl ��? eJ s644/J tri-vte—re-Z c
4.Date Well(s)Completed: 1-13 9.14 Well ID#AA © !• I le ft. 98
ft. Lc I01� . -.
5a.WellLooccation: Phone
ne#:5.33 173 J(77 2D f is- ft .;f0%( • - -
Il haAnA� 4' 1 tur ,t,R�a $ove>N .tdW 6 'i�otit s D f ft I Gft OR /
Facility/OtvnerName . • • Facility lD#(if applicable) l L f Oft. L7/�.ft. j,�.-t j� e fwL(t 61
- S�L 1p6 6� A- p' �L/p
{It ,� : 4�_6tQ// we Y\91_.. -
Physical Address,City,and Zip a 'Stp04 ft ft I f::: :o- .
County '.i Parcel Identification No.(PIN) I �l� L •Zrs .
PA
AI?
Latitude and longitude in degrees/minutes/seconds or decimal degrees: I .
(if well field,one lat/longis sufficient) 22. info Y R 1?r::"..n' r,;l'3i
3t919 (9 /1 N 1 , 1r299 w Certification: D=�ar�; J
(,5—y`r
• ' 6.Is(are)the well(s): permanent or OTemporary Signature 0 edified Well Contractor Date '
By signing ihisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ltro ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the welOwner.
repair under#21 re-marls 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. 1 ' " 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22 (ft.) Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths if different(example-3Q200'and 2Q100) ' I
a 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ry (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
11.Borehole diameter: 6 (m,)Bit Off: C.07 if 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 7699-1636
A I
12.Well construction method: d 1 A. (it p a1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) f/ 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
•
13a.Yield(gpm)
t
Method of test: if 61// Permit Program,1611 MSC,Raleigh)NC 27699-1611
70% hth pp' Date Site Visited: g/3/. 3
13b.Disinfection type: Amount: 1 1 OZ Site Visited By: Al,
' "t ab 6 '` LI
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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