GW1-2021-06792_Well Construction - GW1_20210809

1
'r_"L0 HERMAL WELL .CONSTRUCTION RECORD '
WELL CONSTRUCTIONRiECO RID t
for Internal Use ONLY:
This form can be used for single or nmltiple wells
s
1.Well Contractor Information:
„^✓t 1 �0�` ��`� 14.WATER ZONES 1 !
�✓) �'e" 1 , /� ,� t � fora FROM .TO DESCRIPTION
Well Contractor ame '_F �Fo ft.
3 a ft. f
�\`� �\t GEC J�Oy� M M k
�-� 7�"�
NC Well Contractor Certification Number 3t�"v J 15.OUTER CA IN for multi-c2sed tivells OR LINER if a lice le
FROM I TO I DLSMETER I THICIO'MS L
Yadkin Well Company, ft: ft. In.
Company Name 16.INNER CASING OR•TU G eothermal closed-loop)
O 4 O® ` FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit�: 1/�L .�C� � a., 1 It. �(� to
List all applicable well comouction permits ti.e.County,State,Variance,etc.)
ft. fL
3.Wcll Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIOYFSS MATERIAL
❑Agricultural OMunicipal/Public ft. ft In.
❑Geothemm)(Heating/Cool in-Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERUL EMPLACEMENT METHOD&AMOLM
❑Irrigation 3 ft. (� fL
Nou-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Carapplicable)
❑Aquifer Storage and Recovery ❑ FROM TO MATERIAL Kh PL>,CEMENT METHODSalinity Barrier ft. tt.
[]Aquifer Test ❑StonnwaterDrainage R ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets'ifaecessai
eothermai(Closed Loop) ❑Tracer FROM, TO DESCRIPTION(coler.hnrdnen saillreck type,grain she,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain' Aunder 4211 Remarks fe /O ",
� I •o, -�� Q
4.Date Well(s)Completed: q-a1We11ID#/ 1 PTO- !7 v ft • ?0 R
p ft ft.
;�'_ [
Sa.Well Location: Phone numberzu• n_ ft
-1 ol f fL ft
Facility/O ewn rNanu Facility IDN(dapplieable)
ft. ft
. e�S w,nd���d L� 13GCt'.� 2B"eo1 ft. rt
Physical Address,City,and Zip 21.REMARKS
I/N AT 6-tA q c, 8'U
County Parcel Identification No.
of loos 1per Bore !- Dia. of loo
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwell field,one lat/long is sufficient)
N W -
Si a ofCe ed Well Conti-actor ate
i
6.Is(ate)the well(s): ermanent of ❑Temporary y signing this fornt,I hereby cnv)�drat the wells)was(here)eonstntcted in accordance
,, with 15.4 NCAC 02C.0100 or 15ANCAC 01C.0100 Well Consrfnrction Standards and that a
7.Is this a repair to an existing well: Dyes of It o copy ofthts record has been provided to the well owner.
If this is a repair,fill oid lao>+•n well constructlona htformatlon and explain{the nahnre of fhe
repair wader fll rennarkr section or on the back of this fount, 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: D construction details. You may also attach additional pages#necessary.
For multiple injection or non lrafer•supply wells ONLYwIih the sane consbuction,you can
subrnft onefot•m. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3,5¢O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnuliiple wells list all depths tfdier•ent(example-3(]a 100'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,sue"+'•, 1617 Mail Service Center,Raleigli,NC 27699-1617
11.Borehole diameter: "' (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24'a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following-
(i.e.auger;rotary,cable,direct push,eta) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: 24c.For Water Supply&Inject!I on Wells: In addition to sending the form to
132.Yield(gpm) the address(es) above, also subrriit one copy of this form within 30 days of
13b.Disinfection Type: HTH Amount: CU S completion of well constriction!o the county health department of the county
p where constricted.
Foinr GW-1 North Carolina Depaitmeat ofEnvironment and Naturai Resources-Division of Water Quality Revised Jan.2013
DB•ta Site Visit-edf By: p