GW1--06888_Well Construction - GW1_20241118

In
' WELD.,CONSTRUCTION RECORD (GW-1) For Internal Use Only: '-Tr
1.Well Contractor Information: I
1.
�'Q°�
0.1 P.1,4'•WS.TEgZONES' ;e:;liS..7--•.•.i•,I•..; rve
Well Contractor Name FROM TO •' DESCRIPTION
Uil
�p 90 ft. 95 ft 1 COpiicif _
NC Well Contractor Certification Number �?" fG iyi
—
Yadkin Well Company, Inc. ^°o :USINOVonfililfi,ETEwells)`:ORLCKNEi(ifap-1ielli ;'; e:_ ..CA
TO DIAMETER THICKNESS MATERIAL
Company Name ft• ft In.
:Y.16v'IKNER:C9SING'ORUTTB NGr:'(geotfieFifild trig OW.: :Z ft... ...:
2.Well Construction Permit#: PROM TO DIAMEfieTER, ' THICKNESS MATERIAL
List all applicable well construction permits(La.U1C,County,State,Variance,eta) ` ft. �� ft r' in : _ e
izA
3.Well Use(check well use): ft, ft. in.
Wa}g��Supply Well: t�7IGOEP , 1 . 5 '.,..i.:_r. _ c c
'cultural . FROM TO DIAMETER -SLOT SIZE ,THICKNESS •- MATERIAL F,
�o ,' ❑ clpal/Public` ft, ft. in
❑Geothermal(Heating/Cooling Supply) Uhltcsiciential Water Supply(single) £t ft in,
❑IndustriaUCommercial ❑Residential Water Supply(shared)
atiOII i 18''.`� lest v�,,zR,12• nr. �.• .t"'' '^.'' -,,- -•'-
DIrrrg ❑Wells>100,000GRD FROM TO MAxanTAT EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f' 214 ft I4'0k' Rtsar Pow re�
❑Monitoring ❑Recovery ft ft e1
Injection Well:
ft, ft.
DAquifer Recharge ❑Groundwater Remediati on
iRig S'ANDIGRAMI4A•c pi"ble :'c„ � ' - :,. X ry N,a—
DAquifer Storage andRecove ry ❑Salinity Barrier FROM TO MATERIAL IMPLACE4ENTMETROD '
DAquifer Test ❑StormwaterDrainage- ft. ft '
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) .DTracer ;201DRItt iliGI;OG(a"itacli'aadtiionirl'slieellat'ne"c"essary)
FROM TO DESCRIPTION(color,hardness,soil/rock .)
OGeothermal(Heating/Coo Q Return). ❑Other(explain under#2I Remarks) type,grain size,etc.)
Date WeII Started i' 3 ® ft �� ft ®i p
4.Date Well(s)Completed: 36,,',..?1' Well ID# W 0-1 C• g .ft' ft r'e,1,0.
gi :
5a.WellLocation: Phone# Si k� O5t-Q ft. ft
D.rc -tki iii ell l 2 ' s tie ft. ft. i` r, r
Facility/Owner Name •Facility ID#(rfapphcable) - ft ft
ft. ft NOV 1. u Lc
RZo k A.2-G. P jQA ,. S
PhysicaallAddress,City,and Zip - ft ft -1 r S
e, ':21tRFM,1th1'Cfix�„`F .ig;r:'t. ?i`iT: :iz.}t e.' ',:M,..:: ::::..,l,-,`,t¢.".; r
County Parcel IdrritificatiinNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient)
‘3...; .7
o ® a 9 / / 22.Certification:
� 7 N ®P.- G-r 2 ! w P,�:.
tit
- 6.Is(are)the well(s): OPermanent or ❑Temporary Sigma a of C ed Well Contractor Date
By signing thisfonn,Thereby certify that the Wells)was(were)constructed in accordance with '
7.Is this a repair to an existing well: ❑Yes or !Ka 15ANC/IC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out!mown well construction it formation and explain the nature of the of this record has been provided lathe well owner.
repair under#21 remarks section or on the back of this fonn.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe0DPT or Closed-Loop Geothermal Wells having the same
- construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled :V e 24.SUBMITTAL INSTRUCTIONS
''9.Total well depth b elow land surface: S O& .
For multiple wells list all depths((different(example-3Q200'and 2Q100) ( ) Submit this G W-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 4 b (fn) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC;Raleigh,NC 27699$b17ig
11.BorehoIe diameter: 8
an jBit Off: 7,ci`® 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(ILIC) �.
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air R6e-_ i 24c.For Water Supply and Open-Loo+ 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(gpm) 3° Method of test: A/(' Permit Program,1611 MSC,Raleigh,NC 27699-1611
, ',. ::
70% hth Date Site Visited: j
13b.Disinfection type: Amount:- 31 g OZ Site Visited By: i , i
Form GW-I North C lira Deparhnent Of Environmental Quality-Division of Water Resources i
Price: S4-milk k, $" i f Revised 6-6-2018
L3 h..;