GW1--05134_Well Construction - GW1_20230818

wwi„L CONSTRUCTION RECORD COORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROMTO DESCRIPTION
3 A6,y- ft. 6 7 ft.,,..,,3� 4 4 - 2J .- 7a
1{' ft. ft.
NC Weil Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
Company Name ' '
in. . --ve_L -,.-3
16.INNER CASING OR TUBING(geothermal dose - op)
2.Well Construction Permit#: Y Z.0 ®4.4.1 C 30 FROM TO DIAM1.1LR THICKNESS MATERIAL -{
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
TM
3.Well Use(check well use): ft, ft. in. -
Water.Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. Z-1
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial . , ❑Residential Water Supply(shared) 18.GROUT
❑hTigation -, , i `�\CktiTire�lii jI00,000 GPD FROM TO MATERIAL LA ,MENT METHOD&AMOUNT
Non-Water Supply Wel•,C.Li L.s L.LI 0 it, �e,1 ,1
.�1 L"� ft. tIDnt�v et4- 5 e..J
❑Monitoring 1 n �1�I3.ecovery ft. ft. 1
In(ection Well: O [�[� �j/41 ✓ 3'1l c''
ft. fr. .
❑Aquifer Recharge
in inter Remediation
nr - ij�.fl t7iL`G 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and very DwojitogSalinityBan-ier FROM TO MATERIAL E11EPLACEMENTMETHOD
✓
❑Aquifer Test 05tormwater Drainage • /ft. / • '
❑EE'�cperimenta]Technology ❑subsidence Control • ft f1� / r -
1G/eothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ._ •
❑Geothermal(Heating/Cooling Return)' ❑Other(explain under#21 Remarks) 1-ROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
- -7 6111 /� o ft, lir ft. Sul,• .pl p vvlcid S 1,2
4.Date Well(s)Completed: 7/7/a Well Mt/ A 1® C L y O p ki ft. `3 J ft. iect vj. � � �
1 alrlrk ki Z�'t, ft. . tt. z
Sa.Well Location: Phone # 281- 7os.O2.G( t3� ilk) Nt. Q (�r ,,,,114a. 41
e Init: te(I C-5rniM Ai 44...3'z3 ft.
iiii
Factlity/OwnerName .�,� fL Facility ID#((if applicable)
�1` ft. fLe i Lid ro uir � 41) �,.-
�4 l E.s ci6'dl'hiy tJt d"t+�f/69ejva.`4� .Mv ft• fr• fit Lid
CA)1,,,,. P
Physical Address,City,and Zip / / Ae?665 ft. ft. �� Q,� l Pf,4 c )
)L4✓(i4 P-' 21.REMARKS rr
County Parcel Identification No.(PIN) BORES (I ) DEPTH (StL 1 C�c ' W e l 4 Z.
fi LOOPS PER BORE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ( ) DIA OF LOOPS(( C
(iflvell field,one lat/langis sufficient) 22.Certification: SDR OF LOOPS ( l2 ) 2.,0
'79',303o N 0/, 6 -1276, ' W 7 7 • 1'57 g.
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Ce d Well reactor ate
p
By signing this form,I hereby certi)51 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or ISA 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. . .. li
repair,umder1121 remarks section or on the back of this form.
23.Site diagram or additional well details: •-
8.For Geoprobe/DPT of Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info Cl
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in RemarksBox).You may also attach additional pages if necessary. 9:
drilled: i
,�gg 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �V ° (ft.) C
For multiple wells list all depths if different(example-3©200•and 2©100� Submit this GW-1 within 30 days of well completion per the following:
/0 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater Static10. water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use•44^" gel p1
11.Borehole diameter: (in.) Bit Off: P� 90 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY '
12.Well construction method: 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 IWATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
�- y' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a•Yield(gpm) 7� -/�1(.� Method of test: ,fifer mile' play e
13b.Disinfection type: 70% HTH Amount: 3'X OZ DATE SITE VISITED; -/j- 2 3 Ay.,- 1-D 4,-.
Psi re: VISITED BY: 0' 1,,)0(.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources -r,,,,,lbt /Awe.121 - 6-6-2018