GW1--06152_Well Construction - GW1_20241014

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v'''WELL CONSTRUCTION RECORD(GVV-1' For Internal Use Only:
1.Well Contractor Information:
FROM TO DESCRIPTION [�
Well Contractor Nam AAA�JJJR��'
A.� ^ •- A
low " -S �/ C.—
NC Well Contractor Certification Number ✓��(� �1�
;-1 O1° : G`(f°r>miilfir ed;Welv�':ORIT0NF.R:ciEiip-lii e)l ; • _ • ..
Yadkin Well Company, Inc.
PROM TO DIAMETER THICKNESS MATERIAL
ft. ft in. Ov
Company Name •
• 5601�II1ER;0ASI1!iG'ORTi7BING:(geotIiermalcid'sedloojr)°:;%: �>,: ..
2.Well Censtrnction Permit#: PROM TO • _' DIAMETER ,THIC N SS MATERIAL
List ail applicable well construction permits(i.e.UIC,County,State,Variance,etc) d ft B 11
ft /�j l!�y f/S-2' 6 / `
3.Well Use(check well use): ft a ft in
Water Supply Well: 37 5' ._'.:.;:':"•;-"‹'- ?:;"?,a :.Z;'-.. ;_ry_: :Z 21.. � -
FROM TO DxAMR1En SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) X.esidential Water.Supply(single)
ft / ft ( in.
❑ludustrial/Commercial ❑Residential Water Supply(shared) 11
r'1 Waotft+?. ,r'n'; .; cka<; :;f 1:..i±. :: ,_i :ter:r
❑Irrigation - ❑Wells>100,000 GPD FROM TO ,MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply,Well k o r;; ` "+ ft. ft {� , r
❑Monitoring `� t..s'fl"' '4 DRe L.
ft. 3o ft U( e�� G��,t dI
Injection Well: p r T 1 1 e024
Aquif ft. ft
❑ er Recharge � ❑Groundwater Remediation
IIAquiferStorage�nd.)2ecovery -,-.....7.,.,"at7SalrriityBarrier• F'1'SK1`ID/GRA �LCK('f pp1i�alile}'.,,_.",:Z '..".: ;i+.<_` b '.."a:°;.._
ti :j .'c-. TO MATERIAL LEMPLA METHOD F
DAquifer Test - L:' •='❑Stormwater Drainage ft ft
❑Experimental Technology . ❑Subsidence Control,. ft. ft. •
❑Geotherral(CIosed Loop) •❑Tracer •,,-20SDRIY `1G 'OG(atfieli' tronalshe'eti ifrieces's'ary)'?;_ ..-.,;:''.`_. :7,7V3.'i
OGeothennal(Heating/CoolingRetom) ❑Other(explain under#21.Remarks) FROM TO DESCRIYTTON(calm,hardness,sorUracktypggrainsize etc.)
Date Well Started fi'-14*2f ' ' ' A 0ft d ft •.S 6, 0
4.Date Well(s).Completed: (L1..22 We lID#.•`"G ,�'`. ' r .UV ft D ft 1/fr. 15d�t
Sa.Well Location: • phone#:'�3( .� '7 I ®`Q62 W (j0 ft' �g ft � _
- -125 f' 733 ft t rr 'J. ,91Y' WI"' if'i6/a
Facility/OwnerName Facility 1D#(if applicable) /(/ ft ft ` VAC L- d l e G '
FAti '` ::.,ilk Ales vier •Ai•& bs r ft Loa ft 6 IA Ioe - tiw ..moo
Physical'Address,'City,and Zip ft ft
County ParceIlrtrnt fcationNo.(PIN) WYdjfe( 4
5111 Latituded l and in degrees/minutes/seconds or decimal degrees:
(if well field,one'at/long is snfi'irlent) 22.Certification: �„
369 Li. I ��W" N Er`° 11 J 101/ W
6.Is(are)the well(s): ermanent or ❑Temporary Signature of C ed Well Contrafr::_ _.—
, k.--23-2-4. .,
Dare
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance'with '
7.Is this a repair to an existing well: DYes or Io 1SA NC1C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy -1 •
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 well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeiDPT 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: P i='
p 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 100; (ft•) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths(([different(example-3@200'and 2@100) , g'
t 24a. For All Wells: Original fork Ito Division of Water Resources.(DWR),
10.Static water level below top of casing: 'f 5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" N
11.Borehole diameter 6 (in,)Bit Q f f:5' -< f 24b.For Injection'Wells:Copy to,DWR,Underground Injection Control(IUC)
r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: el t f to 1-49//. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 03
(ie.anger,rotary,cable,direct push,etc.) • county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • rid
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA ..p-"
13a.Yield(gpm) Method of test: P% 0.� Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: S -?3;- Z y �!
, 13b.Disinfectio pe: Amount: �� 0z Site Visited By: Chi
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Form GW-1 J W North Carolina Department of Environmental Quality-Division of Water Resources . Revised 6-6-2018
Price:_
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