GW1--02297_Well Construction - GW1_20240410

" LL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
.Well Contractor Information: 2.
L C Y CA)J.J Il'C-.1%1(AI 15 )r
.ia.wATllizor>las
FROM TO .• DESCRIPTION
Well Contractor Name •
93 ft ft `���
Li s 6 ft , ft
NC Well Contractor Certification Number 15:OUTER'CASING(for'iuulti::d sed.iv. ells)ORLIMR(if iiir licable) ,;,___
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
.+ 1 ft. 0) ft L.9.( in. SCM-Z I 1" uc.
Company Name 16:]INERCASING:ORTBEG(geotheralclosedloop) _ ._ - - -
2.Well Construction Permit#: I V., R.) FROM TO DIAMETER nacKNEss MATERIAL
List all applicable well construction permits(le.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in. c
Water Supply Well: 0.72 T:
FRONTM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�/unicipal/Public ft ft In.
❑Geothermal(Heating/Cooling Supply) [OKesidential Water Supply(single) ft ft in. ,
❑IndustriallCommercial ❑Residential Water Supply(shared) :7..is:GROUT' • •re
•
❑irrigation ❑Wells>100,000GPI) FROM TO, TERIAL EMPLACEMENT METHOD di AMOUNT
Non-Water Supply Well: n j a ft 7 ft. �.,+t sz a,c,y 11 t tr. '3 IN
9
OMonitoring (Recovery ft. it. 0'
Injection Well: ft ft. P
❑Aquifer Recharge ❑Groundwater Remediation
119.SAND/GRAVEL PACX Tiif pplieable):.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM IAcEtvomTMETHOD O
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
®a
OGeothermal(Closed Loop) ❑'racer '20.DRILLSNGLOG(attacbidditional sheets ifnecessary) - _ ... __ _.-
•
FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,de.) '"",-;E
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (' ft ft ur t �.�(a
Date Well Started v y' I t-2-4 d•a-° 9 3 .. ft. S ft
4.Date Well(s)Completed o -1 1'Z Well ID# N ,� 0 Pi r+
5a.Well Location //a a#: i 7-- (. ft. ) (7 ft. 5!yen I ,•�.
�� .�
�i�- I/ GvJia �e r✓i+ ft. , u rJ ft. :(,a A �
td?rl,sr\ i�.s®�f $i�4� � af�ae.Iav A�e1Av �L"
Facility/Owner Name Facility ID#(if a licable) ft ft
nevi p((®le,,,*1 ti + . c' �C. 12i A ft. ft l ,.
L �..r :""4. ..
Physical Address,City,and Zip t�v c i/ a%tel 10 ft. ft A P o 1
K/,f/4 e i �6"44L q =REMARKS. ,i .a V (1114 --
County Parcel Identification No.(PIN) !;lit..i.-'• F
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 • �. calicoR.: +' / i..,�i „ 3ft'i` ) N e0, ,9,-,k19 " w i ' / rit 3'3_1 Q -Z.
� 5 e of ' ed Well Contractor �' Date ��
6.Is(are)the Pi ell(s): iiermanent or OTemporary
� By signing this form,Iherebycertify that the wel(s) as(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or It1Vo 1SA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a copy
If this Lea repair,fill out]blown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#2I remar1x section or on the back of thisform. 23.Site diagram or additional well details: 01
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: 1 4 1 (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2©100')
//�� 24a. For All Wells: Original form to Division of Water Resources (DWR), t
10.Static water level below top of casing: lJ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
s 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 4� (in.)Bit Off: Q Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: `rO r W`i 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 01
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 74
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
it Permit Program,1611 MSC,Raleigh,NC 27699-1611 4
13a.Yield(gpm) ,® Method of test:
70/o
o hth 3 oZ Date Site Visited: )l -�3,- 2 '• .
• 13b.Disinfection type: Amount: Site Visited By: `o, ---
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018