GW1--04415_Well Construction - GW1_20230710

'WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: P 1 ad
J r r;14 WATETtZONES --
FROM TO DESCRIPTION
Well Contractor Name �� ft. ft � �g � � �®�� " '
44
d��� ft ft
NC Well Contractor Certification Number • 15::OU.LItt CASING(formiilti=cssed:wela):ORLIlVER(ifap livable):_ '.....,:. .
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in. ICJ '
CompanyName C4[cl wQ ut g 28--c/26-gs 19 16ANNER CASING.OR'.TUBBING:(gedthermal tidied=loop)"--'--_-- �'
2.Well Construction Permit#: 212, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC Comity,State,Variance,etc.) t' ft %if ft / in. (t� 'Ai P7frc
ft ft lP in. v
3.Well Use(check well use): t
ki
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Z
❑Agricultural ❑Mnnicipal/Public ft ft in.
°Geothermal(Heating/Cooling Supply) [residential Water Supply(single) ft ft in.
0
❑Industrisl/Commercial ❑Residential Water Supply(shared) 18.GROUT - - , _._ _ _ :---- - - -
•❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIALL EMPLACEMENT TT METHOD de AMOUNT
Non-Water Supply Well: 0 ft' 3/ fth G\i 5 l� Vt d t 22 8
°Monitoring DRecovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
..
• .19::SAND/GRA'VEL•EAGK(ifapphcahIe). -- -. .- - ---_."__...,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD - -
❑Aquifer Tett ❑Stormwater Drainage ft. ft a
°Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed.Loop) ❑Tracer 20.•DRILLING'LOG_(attach additional slieets if necessary) __-_-_ - -- - -�
FROM TO DESCRIPTION(color,hardness,saiUrack type,gain size,ate)
❑Geothermal(Heating/CoolingReturn) El Other(explain under#21 Remarks) ft. IV
ft �� 1 s e �
Date Well Started Completed:
t'�.' e y� C t^j 17 1 J
4.Date Well(s)Completed: �:'1A�'a Well ID# t3 11 t
ft. 53 ft. :1 Sitn ,
5a Wellll Location:_
Phone#: Z� 3 Lc�‘ 53 ft 3'9 ft. ,sy + D'i5 -g'�f O f ani 3
1 ' t' i/ - L.0 Q trl o yy�� AA 'r ft. ft. T
h �i� ]�' = I�V4�W` 4tstn'►� / ft ft r�� ' F
Facility/Owner Name Facility ID#(if applicable) r~„- L -. 7 "y',:ti
1 L /f Za C.IV X AI fe '� iit, ft. ft
Physical Address,City,and Zip ,` @3 5 ft. ft J'U L 1 9 2023 0,CAM(we II
•(PIN) NI..:ti ,
County Parcel Identifioation No :•!y'.,. VI
513.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one latllong is sufficient) 22.Certification:
3S GIrV2 C/N i- 7- W ,/7
, �` Signature of Certified Well Contractor Date
6.Is(are)the well(s): L ermanent or ❑Temporary
By signing 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 l!JNo 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards 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 to the well owner.
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
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 1 GW 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: 3 9 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a)200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: a® (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (m)Bit Off: '��� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply 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 SIIPPLY WELLS ONLY: a 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
ail 1 r" Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of test: ��3
o wy Date Site Visited: ii-Z rC
13b.Disinfection type:
70/o hth Amount: "p Oz Site Visited By:
Form GW-1 Quality- Revised 6-6-2018
North Carolina De�,artment of Environmental k Division of Water Resources fl
Price:,". 1L. A