GW1--03914_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ontractor Information:
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Well Contractor Name / ,n„ FROM TO DESCRIPTION
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V�n s— ��iro.�'��.� �a 4....�,d ft. 'ft
ft ft
NC Well Contractor Certification Number I i I N 2 `2023 -15'OUTER'CASIN-1 fon'mulfi=cesed'vieILi'012I]1VFdt'ff'a"`liczble" _' ""
Yadkin Well Company, Inc. J U FROM TO DzaM�1�R Talcs;ws I�aTERrai
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Company Name Ini'Df�*•'�'h' � .� � � � t
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p� 1 h,n Cirt'%`G�f9�1rn,� ._16i•1NNER�.CASING�OR.TUBING:('eotHermal"closed=loo' ��- - -
2.Well Construction Permit#:��rt F -01 13 /J - �V 2- FROM TO DIAMETER THICKNP-Rs MATERZpL - -
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc) ft ft. in. A
3.Well Use(check well use): ft. ft in
Water Supply Well:
FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) [516sidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) _-_
❑h2i ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUM
Non-Water Supply Well: 0
R ft o h /_
e�.7�
i et
❑Monitoring ❑Recovery ft ft.Injection S
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation
• _'19_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLAaMUNTMETHOD '
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer `.'JKDRII'SIlVGIOG'affach'ac33itionalsbeefsifnecess"'
❑Geothermal(Heating/Cooling Re ❑Other(explain under 421 Remarks) FROM TO DESCR MON(color,hardness,sm7lrock type,gr2in size,etc
Date Well Started 4 ft r 51
4.Date Well(s)Completed: 'S Wel1ID# - ft- � it ���/ eo_
5a.Well Location: Phone#: -83 r1 Z ft ' ft
6-kk s9 ft ft.
Facility/Owner Name Facility M4(if applicable) it. ft
I 13 1 Cv¢a� �� J®�est�e'��. ft ft
Physical OAddress,City,and Zip ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degre
(ifwell field,one lat/long is sufficient) 22.Certificatio : P
N
6.Is(are)thewell(s): Is�ermanent or ❑Temporary si a ettifiedwellContractor ate
gning this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or !1No SA NC-AC 020.0100 or 15A NCAC 02C.0200 Well Construction Moidards and that a copy
If this is a repair,fill out known well Construction information and explain the nature of the of this record has been provided fo the well owner.
repair under#21 remark section or on the back ofthis form.
23.Site diagram or additional well details: a
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 I 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: r r (ft) Submit this GW-1 within 30 days of well completion per the following: 4
For multiple wells list all depths if different(example-3Q200'and 2Q100D
10.Static water level below to casing:
/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
p of g: (� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" +�
11.Borehole diameter: C, Cm,)Bit Off. �t�? P24b.rog For Injection Wells: Copy to DWR,Underground Injection Control(RJC)
,, � Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: tx-I tf f 9D t 4•' ,`� 24c.For Water SnppIy and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: �j 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method oftest: /let/ Permit Program,1611 MSC,Raleigh,NC 27699-1611 lII
I
70% hth Date Site Visited: 4-- �7
13b.Disinfection type: Amount: OZ Site Visited By: Aa
Form GW-1 North ciarolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price:, i