GW1--04419_Well Construction - GW1_20230710

- WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: f a
r 5 .3 •ey r/Gt.0/ I.✓. 14;WATER ZANES'';:=.::'.'C;:': ''.. _.: :. •.. ' - .__ - - . _ : .
Well Contractor Name FROM /TO DESCRIPTION �a
SO3i '— IA w .;P!; L. ,` A/�� ft ®�� ft �]i G� /� y(7°`3�J� i� �P�M
�•. ,C.,.6 v L.., '1 lob ft LtvS ft I/� GPµ"
NC Well Contractor Certification Number �I I� j r1 Z O Z J 15..-ourt:tt.CASING(for multi=cased:vrell5)ORI NER(if applcable)'=_�_
Yadkin Well Company, Inc. J - FROM TO DL�METER T`E�I/CIpNESS ..... .�ERIAL
, ( ft. i Set ft L e 2'S m. of ®0 C+t•f 4•44 'g:r
Coman Name M
P Y sss`,::>) t :ar ^srµ,r'. ;:r,ti. '161HNER•CAS]NG'OR.TUBING(geotHermareltsed�Ioop)-i''i - . -
_ _-_ -
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2.Well Construction Permit#: a'�i 1, trt ):�r•Z,� FROM TO DIAMETER THICERESS ,MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,eta) ft ft i13•
3.Well Use(check well use): ft. ft in.
Water Supply Well: FR ITO DL1M&TE8 SLAT CT7t+ THIClfNESS MATERIAL
°Agricultural ❑MunicipaliPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) 411esidential Water Supply(single) ft ft in.
❑lndusirial/Commercial ❑Residential Water Supply(shared) . .- . . .
r1$t;GROUF
❑itigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD Sr AMOUNT
Non-Water Supply Well: 0 ft. ft $gn-�•ay;ff ( j Plq ! yP,,,, �4c
❑Monitoring ❑Recovery ft. au ft t',,,Sitivr f µ"^ ed
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediati.on
i 19.SAND/GRAmi•PACIC•(if ipplicable) --_ • - ..-. .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' -
❑Aquifer Test ❑Stormwater. Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer '':'20'i DR7) VGZOG'(atfaelaid'diiibii$L alieefs if necess'aiy) :_.._ . _ .
FROM TO DESCRIPTION(color,hardness,soillroek type,grab3 size,etc.)
❑Geothermal(Heating/Coolin Return) ❑Other( lain under#21 Remarks) ft, ft t) St t�J
Date Well Started I2/,& go� .J3 C6� Sy .gear r,P l Si f y r
4.Date Well(s)Completed: 943 Well m#f 1A ' ,'�di ft' DQ f t 6 e+col:4/,4i( it!P 574...e. i
°
5a.Well Location: Phone#:70 -y7 j— �)2. ®®ft t 0 ft l.�ytr-5 6r�ot,ty,�' Po�K 4-[/1,43.ci A-
N.L a~ GG trCt 6 e 1 i[a AU A ell'eCiel Gla"6-ems' 00 ft. Oct ft g-i,,,tr-ie 14,,,,y —e ,, y'
Facility/Owner Name Facility ID#(if applicable) j g q o 6c 4/t rP -, �,®o�.eYs t 67'f' 71-01,;te
/d c.illy e. ft. ft /
Physical Address,City,and Zip ft ft
CoDa*
v I Parcel Identification No.(PIN) a iym n, 4 A 11`••• rii, .cd- elLS
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/ong is sufficient) 22.Certifica..n:
/441--;-,e/ 423
6.Is(are)the well(s): �brermanent or ❑Temporary Si„ r ed Well Contractor Date
mg this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: •❑Yes or 1l4o A NCAC 02C.0100 or 15A 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#21 remark section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobelDPT 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: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .lr1 CO' (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100)
t 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S6 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: is (in.)Bit Off:6 r Dc9 7 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 14 t✓ A biV.v.y 24c.For Water Supply and Open-Loop 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) S Method of test:rt t 4 Permit Program,1611 MSC,Raleigh,NC 27699-1611 U, , ` (1. -
70% hth do
Oz- Date Site Visited: 11 2Y-L 3 �
13b.Disinfection type: Amount: o Site Visited By: 0 1 n�
Form GW-1 North Carolina Department ofEnvironmental,Qgality,-Division of Waf Resources ., --
. Revised 6-6-2018 e.
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Price:_ f e I Zr5
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