GW1--04420_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
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C r0 e/�.41r^E(/"_ e-� ° i14:.WATER ZONES:_- .. -
FROM TO DESCRIPTION
Well Contractor Name A 6 :i .v Y.., a-. ;® ft- 2.5 ( 99
` 01° ' e/l
NC Well Contractor Certification Number J U i j n 2023 :,15.-OUTE&.CASING(for.multi-cas'ed,iirelfs)OR'LINER(ifap licable) '_ ryl
Yadkin Well Company, Inc. FROM TO DIAMETER I ' THICKNESS MATERIAL
n s.. ft. ft- / /e� in, ry�1 f
Company Name �/ r E.'$1 ._�•^,. , rl , '+{z- 1 i `�'� �� (9s1d�' �U(� ®t� �/
( � 3 W--7 J��t7 /6'`ie,.. • ) .l :MANNER, CASING.OR.TUBING(O ithermal dbsed-loop) ` - -. M
7! FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3 g el 3(z 7
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fL ft in• ems'
ft. ft. in.
3.Well Use(check well use):
17.'SCREEN,.. _:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothennal(Heating/Cooling Supply) i3Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Itrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT jja
ft. ft. 11 //.. �/j l / I '16 5Db1s
Non-Water Supply Well: ® fff Dd®I J f Cl/L� f yr) I a.. PA" `� ���
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑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.DRILLING LOG.(attach additional stieets if necessary)`;':' " • ._ '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillroek type,grain size,etc.)
Date Well Started 0-7/Jt,-c./'7- AA //�� y� �-i Co ft 13 ft. 40: I�_y i Locs,G � -v:a,e s
4.Date Well(s)Completed: /'C,,,,.t/ 3we11 1D#4AP''1 , 7 is ft. --a.�j ft. e dt g/�'De,'•,� 5 iie-tS'
5a.Well Location: , Phone#:S3 j 7I-2eCI /o ft- , el ft. j 4.-3 C9�:1aaw.rk pr/`��1Di..A4 ea-4
�� Freya
se( ft. 6 t ft. Ovum r� CTv e.)/ i
Faciiliity/Owner Nara Facility ID#(if applicable) �gi ft. /f,01 fL tf /' I t t I
/ q, b/af.2i�9srei c,, f'`ems' 1,1Q,4,11..
°L. 'f.v'.// g!) ft. I�'+�� ft 6& Z.^J`'• (T�` &74/ a i
Physical Address,City,and Zip (C�� O1 ft. tt� J.�� 0 a/)f iv i! y /Jj-a-
l��i/J `,21gt.REMARICSr:.. i �/. r �:
County Parcel Identification No.(PIN) �"'e9 �s � ! � 6^ a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L11 ®terf-1=UOp
(if well field,one Iat/long is sufficient) 22.Certifica•on: (, .•SR "f 1os ) �y3S -(r6 , 2N 8'O2 -, '-7 W 0 `�f // /cb23
6.Is(are)the well(s): t1 rmanent or OTemporary Signal C died Well Contractor Daie
B sign' 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 QNo CAC 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. 4
repair under#21 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/1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional page:.if necessary. aL
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10'9-- (ft.) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths if different(example-3 r@200'and 2@I001
24a. For All Wells: Original form to Division of Water Resources (DWR), EN
10.Static water level below top of casing: (ft.). Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: On.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Q Program,1636 MSC,Raleigh,NC 27699-1636 �j
12,Well construction method: iti 1\cis �=r"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 1J11
FOR WATER SUPPLY WELLS ONLY: ,, 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield A ,tom f Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gpm) Method of test:
13b.Disinfection type: 70% hth Amount: P 1 oz 21.1
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_ Form GW-1 North Carolina artment_tajgiv onmentnl_Quality-Dividon o Water Resources` a -t Revised 6-6-2018
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