GW1--03245_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: =
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1.Well Contractor
ECoontractor Information: 1Y t a C 4-(i/A C-0-i/t- 7.14.WATER ZONES FROM TO DESCRIPTION 4
Well Contractor Name
ale ft. e1(1 ft. -<
3 `rI .-( ?'A- ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for morn-cased we:Els.1 OR LINER(if ap licable) 1
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in. , (-1,
Company Name �Jt 0�i 16.INNER CASING OR 1'UBING.(geotherinal cloned-loop)
2.Well Construction Permit#: 82 V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits tie.UIC,Comity,State, Variance,etc.) f. ' ft. 7?
6.ff ft. 11� in _v i xi PVC
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) 114,Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. (97 ft. BAL tit r . C�J pJ pow ei
❑Monitoring ❑Recovery ft. ft. r I S tooD_S
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL'PACK(if applicabl Z
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑13xperimental Technology ❑Subsidence Control ft. ft
DGeothennal(Closed Loop) ❑Tracer 20.DRItLINGLOG(attach additional duets ifnecessary)
❑ ['Other(explain under#21 Remarks) FROM TO nEseRiPxloNSeomr,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Retuna
Date Well Started 3-).6-p` a/��j I I U ft. �/:t ft. C'
4.Date Well(s)Completed: Well LO#O (AQ 1 It. ce ft ,J •/74/3 1` -rod
5a.Well Location: a hone#:8L%- -773-Gi71 6'7 ft. 21� ft. havd _ . C.
"I C W C(/'iity co(
o f ft. 36 S ft.
t srp.
_ ' 'L
Facility/Owner Name Facility lD#(if applicable) 30 S ft. 90 ry ft M e� fey
N ft. ft.
Ne N Iq9 LVvA►_NI,`, a Gv7 -
Physical Address,City,and Zip ft. ft.
a /a 21.REMARKS
County Parcel Identification No.(PIN) S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IV�qq
(if well field,one lat/long is sufficient) 22.Certification: L�t.7
1
3 6 021 IS' N �SI 21 / 3I/1 W
111, l'c -a -
6.Is(are)the well(s): Permanent or ❑Temporary Signature o Certified Well Contractor Date re/5
By signing this form,I hereby certify that tie well(s)was(were)constructed in accordance with `"\•
7.Is this a repair to an existing well: ❑Yes orIo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction n formation and 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 GeoprobelDPT 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).Yost may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS 4.
�lo�l
ft.
9.Total well depth below land surface: (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')
no\ (ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 2�/ ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 .-r-
If water level is above casing,use"+"
11.Borehole diameter: (in-)Bit Off: C.(0Ul,0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
?
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: (kr r ry ' �ry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(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
13a.Yield(um) I Method of test: f•1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
(0 f ic
hth
_. Date Site Visited: k/ /S Z 3
70%
13b.Disinfection type: th Amount: ,,,,,of Oz Site Visited By: /1,'
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: StA, (4,,,4,r t, LA-