GW1--05158_Well Construction - GW1_20230814

Va,r L L CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well lContractor Information:�or/� `
ko
FROM TO .DESCRIPTION p e
Well Contractor N /N�\` �i�•1 ;ft. T 's •r 7fillillt. "'" 7.-y4 /0 q "-,� (•�'tt /q/ *f' sfti � gu '2Q7 Powt� &N s`�f1fiell ContractorCertificatienNumber 1` S:.OUT CASING form 'ims)ORlJNER(Kap_licaJ1 "- a�®j
NEW 3 ( 11
Yadkin Well Company, Inc. ` FROM TO DIAMETER THICEESS MATERIAL /A
ft. ft. in.
CompanyName Ran 1 `0
I, 35L• lfk �« _1(S1HIyp1tCASIDIG.OR.TQBING:(geotliermalelotedloop)- - -•-------- ----
2.Well Construction Permit#: L3 (0- 0 a,rci FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG Comity,State,Variance,etc.) 4) ft. 341 ft. 6.73' °' , I ¶ 6'c(1y
ft. ft. in.
3.Well Use(check well use):
Water SuppI Well: U. E ._ ——— R T SIZEFROMTO THICKNESS MATERIAL
❑Agpcultural ❑M/uunicipa]IPublic ft. ft /
in.
❑Geothermal(Heating/Cooling Supply) El esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
• ;'28:GROUT —
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD dcAMOUNT ��
Non-Water Supply Well: 0 ft.
e,' ft. Oer e,Qj fav,r
OMonitoring ❑Recovery - ft. ft ��
Injection Well: ft ft
❑Aquifer Recharge oGroundwater Remediatian —
j.19.BAWD/G ANYLPACK.(ifsPPReable) - ..Z.-❑Aquifer Storage and Recovery - ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft. P
❑Experimental Technology OSubsidence Control
ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DR1IIIIItGLOG.(attIehidditlonaIaheeetaifnehBiiiy)_-__ --------------- -
PROM TO DESCRIPTION(color,hardness,so0hoek type,prate size,etc./
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)Date Well Started 7•-?O -)C 3 0 ft fl'•ft ft. �S+e•L,CM 1:Ke l
4.Date Well(s)Completed 7- 20 Well lD#,/ ,+' �� ?? .�-�' rT�. �r is �'
Phone#:3 ' y:.2.- Ti? 7lI ft xa.7St /'� 'a 6 e firW"•
5a.we11L°cation: Aar i" /tsy*s
7C RyCet 14.4el(tzit M-2Cr4a A4
ft. ft
O Faclity/Owner Name 1 Facility lD#(if applicable)
�(i 3 o !o •- -et. C .u•.. -�)r (Lk i/ O,A �
T ft ft . . ®
r
,/ Physical Address,City,and'Zip 1121 f3 •(''.'" *G i'i f '� -..%
(GK fie( AUG 1 9f1�� ;
�j County Parcel IdentificationNo.(PIN) ,.u L J
s.
T•,,,f 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Irks .. ,
(if well field,one lat/long is sufficient) 22.Certification: CI,3,0r31 .v'J Uirt
35',SI'7 o' N 79, `2.3 30- w � ,-7aAr G
� Si o Certif Wei contractor Laze
6.Is(are)the well(s): 1B/ermanent or ❑Temporary
, ( By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with �'
7.Is this a repair to an Busting well: ❑Yes or -,o• ISA 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 explebs the nature of the of this record has been provided to Maven owner
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: 1
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is/ceded. Indicate TOTAL NUMBER of wells
(add'See Over'in Remarks Box).You may also attach additional pages if necessary. .
drilled a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ; � (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(0200'andzgt00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
101 Static water level below top of casing: /0 ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 4. (in,)Bit Off: 6. ens' 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A 0 l t` 0e 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(i a 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
b * Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm). -1S Method of test: /ci rr ies 4/y
° p Date Site Visited: •'23
13b.Disinfection type: 7D�0 hth Amount: /.J oZ Site Visited By:
Fornj nvironmental Quality-Division of Water Resources Revised 6-6-2018 C
Pn I — C�[tc ..l<- t+�.