GW1--05184_Well Construction - GW1_20230814

. WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
__ t) V PO 6 w14.WATERZONES•.; - ,
FROM TO DESCRIPTION
Well Contractor Name
95 (05 did V. ft. 10 ft Irk° brad,'6R5:1-- 6 6Fil
ft. ft
NC Well Contractor Certification Number •iii
115:OUTERCASING(foi•multi=isased'wells)'Oft LINER`(ifiip'licablb). _
'Yadkin Well Company, Inc. FROM TO DIAMETER THICIINFSS MATERIAL
ft. ft. in.
. Company Name o .,
g,�J `i16:Il�INERCASING.OR:TIIBING:(geotliermal"dosedlIoop)'••':_ � .. _ .._
2.Well Construction Permit#: 3 ,[ l l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.UIC,County,State,Variance,etc.) `4 ( ft. !s ft. )_ in- 1_ -Pi> /' lit v��trt l in'
3.Well Use(check well use): ft. c� ft vt in 15� 4�
raX -
Water Supply Well: FR M��TO•- DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculttual [Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) •. - - - - r
18:GROUT ;.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMODNT lK
Non-Water Supply Well: 6 ft. 'SI ft co,,} Fee' is( 4�c
❑Monitoring '. 7,,( "_.,, t'i .y 71Recovery ft. ft t/
Injection Well: e ,4 4.-.°-J'`...s k"'..." .
ft. ft
DAquifer Recharge r ❑Groundwater Remediation `
AU -
`- L I'::191SAND/GRAVEL PACK(if:a`p'plicable)`,'r . .',:•_" _ . .. .
❑Aquifer Storage andlkttecovery ❑SslinityBarrier . FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test lr,!0-.V.p.` ^+1 Pf.-_.!,..7=';r;QShinwater Drainage ft. ft A
['Experimental Technology;'.a',2i0 G ❑Subsidence Control ft. ft
OGeothermal(Closed Loop) ❑Tracer "20:DRIL*.INGLOG(iittadilidditioiialslieetiifneceisaiy)__-.`. __ 3
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) A
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21Remarks) �rtr�.
'Date Well Started 7-21- i It ft. 's ft o
il
4.Date Well(s)Completed:7"2'j Well 4m#� P� t.7 15 ft• sc ft prom httj 81 1r
5a.Well Location: Phone#: ,Rs a o 2 v�-1 s 6632,so ft. 1� ft 5i,,f 3 l_f
�Qa ft. g'i ft ^l Jtlip
�b .ey4f� pRAvg. LIy
Facility/Owner Name Facility ID#(if applicable) P7( ft i n`� ft. �( Jt alp l'. p 11
e fe,,,,i� KR�eo--- 'a•
da• @e� 0 s, i�� l ft aaAd�ft /•fl+� 'G/�"a iot�l�9'�q+o/ sJI�C 14v/1 .
Physical Address,City,and Zip ?gal? ft ft
County ��� �t� n✓ Parcel Identification No.(PIN) Mi '�t) -t\ tti !j �' S ®pf r)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Silt Q. i' iiri ht be- Al'-irGiei
(if well field,one lat/long is suffircient) a 9 22.Certification:
-)6o1ReJ latl,� S I c N g `°491ilg5?9 W • 'r` l 9a�D•
6.Is(are)the well(s): Permanent or ['Temporary Signature s Certifies ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.1s this a repair to an existing well: ❑Yes or bl r o 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•"d explain the nature of the of this record has been provided to the well owner.
repair under#21 remarlr 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 GW1-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 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: LP5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" /
11.Borehole diameter: (in.)Blt Off:5�Y(v 7 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: IIla, 1 4 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 4
QQ 4> Permit Program,1611 MSC,Raleigh,-NC 27699-1611
13a.Yield(gpm) 15 Method of test: Ft.A""
70n/o hth j Date Site Visited: --le - g Y- (41'it 7 t 01
13b.Disinfection type: Amount: •/ OZ Site Visited By: ire
d ' tr:, D
• �.
s.
Form GW-1 t1Assfd_- N...+ti r-,errsn.....,tn,-..±... --.:-..-.- uality-Division of Water Ro ��/t' Revised 6-6-2018 -.(�
Price: : 0-1. ifIr El 1