GW1--04469_Well Construction - GW1_20230710

NV ell CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�ou.JC C Ibt� 1/i/ . El-C.WATER•zONES ._ ._ ...`.:;_:_.'_'.::15....... •..•..... ., ::n .r:,:' _"Ii•::,
Well Cantmetlor Name C FROM TO DESCRIPTION
35'..'A . „D ft. iS5 ft 6 C.pi„,"
NC Well Contractor Certification Number a 7®ft. 51$ ft a cv���
i15:'OUTER'CASING'(focmiilti=casedwells)ORI1NER4fap-ticable) ___.'.:`.::: .-:F3,,
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. l/0'9 ,` -J d ft 6 in. 0 j 63 6�f1�+�1*�
Company Name
j G .16FINNER•CASING:OP.TUBING;(geothermalclos`ed=Iaop)`:' _ •�-'- :s:
2.Well Construction Permit#: 0 1 kr i WA-) FROM TO DIAMETER THICKNESS MATERIAL.--
List all applicable well construction permits(i.e.MC,Comuy,State,Variance,etc.) ft. ft. _„-tl ln� - r-
3.Well Use(check well use): ..----..,...-ft.-- - ft. in --,
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERAL•,-'•.C-
❑Agricultural ❑Municipal/Public ft. ft. in. �,� --.. -"
❑Geothermal(Heating/Cooling Supply) piesidential Water Supply(single) J___ft ft" - lii
❑Industrial/Commercial ❑Residential Water Supply(shared) :.;18 GROAT---_-__ .._ _
❑Irrigation ❑Wells>100,000 GPD FROM , TO MATERIAL EMPLA aim,•:s METHOD&AMOUNT
Non-Water Supply Well: 00 ft. f et ft. 064,1 j, 1e 1 d
❑Monitoring ❑Recovery ft ft 1� / 3
Injection Well: - ft. ft
❑Aquifer Recharge ❑Groundwater Remediation - - _ _
❑A uiferStora Storage ❑Salmi Barrier n`19 SAND/GRAMtLPACK"(if:npplicable)`:.__ _
q g Recovery tY FROM TO MATERIAL EMPLACEMENT METHOD ' -
❑Aquifer Test ❑Stormwater Drainage ft, ft _-_____,_------- ._,
❑Experimental Technology 0 Subsidence Control -•-ft: ft.
❑Geothemial(Closed Loop) OTracer '20DRIT,LY -GLOO(attachadditionalshe`et;ifneceeeafy-) - - __ ill__
❑Geothermal(Heating/Cooling Retinal ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sci]/rack type size etc.)
Date Well Startedadf e13 - 0 ft. „...)
no ft 5441.4) G o®S t° . S 1.,-e-
4.Date Well(s)Completed:t 'L1 I22 Well ID#_ A P'; 1 1(O ft ft -
• 5a.Well Location: f Phone#:3 -,c72-.2601 (y1 f0 ft, 10 gf ft Gdvr�i 4.--1 &r[-)'f ii.4,,,d / ,
3.a^h /i/le'i( ic, l ft. - ica ft f- i.,,,„JJk-_ ( iii -'/T�'c
Facility/Owner Name / Lr Facility ID#(if applicable)
ft ft G r.
/ ' 2-( �e\!L� / J o" ,J 7hl� 4 t(r ft. ft.
Physical Address,City,and Zip K,C4n o ft. ft. ... Y - -- --
VV i 1 .e, . :�21.RRMARTCR;;__. .__._�-'..- r7�
County Parcel Identification No.(PIN) •
JU1 I. U 2.023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(ifwell field gone 1st/long is sufficient) p . cation: ff 1 ;'' -. ' i�f
3'( a...-1srsS s� !90 N 2 ` O? & L (0 ;` // /' •,n; ~�,.;�:; , ,7�6t.,.��
6.Is(are)theweIl(s) t ermanent or OTemporary S'..:., eo't ertifiedaell'" Contractor Date
igning 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 It?'
o SA 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 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 pages if necessary.
drilled: l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2° (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: L i (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" / /
11.Borehole diameter: (in.)B it Off: i . '(,C) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 14/ " R° 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the L
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed `2
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
r .___n Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) u Method of test: ( ✓ �.4,4,
Date Site Visited: .)-(7-Z3 ,,/"9e��,} S
70% hth oz ty. c...,4-r-;.c 9 ..14-
. 13b.Disinfection type: Amount:_ Site Visited By: D
gy�'�
(10 (40.4FLV 1.
Form GW I ___- N .+ti r`.nGnaj3P,,...t+P,at n{Bnyimnmental Quality-Division of Water Resources Revised 6-6-2018 °
Price:. �'