GW1--05288_Well Construction - GW1_20230814

' ~ WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: .
1.Well Contractor Information: ,
l
r rno 5-5.4:Wi4TE$MONE5 %.. ,_.,,a,,:.;, . '•?;a :-, ....',_......_ ... ...?::a:. .
N FROM TO DESCRIPTION
WellConiractor
ft. ft
Ps7?o4- f. ft
NC Well Contractor Certification Number 15:;0DItIR CASING(for:multi-casedwels):ORLINER(ifa"livable)r'=MF '::• :1;
Yadkin Well Company, Inc. FROM TO THICK/MS MATERIAL 1
ft. ft.
DTAMETF.R in. �
Company Names. .- ;::::•.:... ,
':.16i:INNFR CASING.ORR.TCBING:'(gerithermal.do`sedluop) :`_ .,:..:�<»ZS >;
2.Well Construction Permit#: PROM TO DIAMETER TRIMNESS MATERIAL
List all applicable well construction permits e.WC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: :1.7-WEI L11:.,.;�.� It 'L ._"_ .-_,. h'.- ,.-;.
i FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i agricultural ❑Municipal/Public ft ft, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) :Ii a
❑lrrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEmerrrMETHOD&AMOUNT _...
Non-Water Supply Well: ft' ft'
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ,❑Groundwater Remediation n
i;B.Iiis:93VD%GRA`OF.LPAG&'(i£ipplicatile) 2 a_. `5. .0.0
❑Aquifer Storage and Recovery ❑ M Salinity Barrier FROM TO MATERIAL EMPLACEMENT ETHOD K-
❑Aquifer Test ❑Stormwater Drainage ft. • ft.
DExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) DTracer 2017)R11 1GLOG:rttael;additio iil:sheeli ifneceesiry):4 ':=: - _...C'Z ..y
❑Geothermal(Heating/Cooling Return Daher(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrack type grain size,etc.)
Date Well Started 7-p I-e ( 02.ft. �', ; • , ter 0-e .. •
4.Date Well(s)Completed: 7-;4.4-�' Well ID# ��g ft. ft.
Phone#: 'loll-SI,-.r( 1 ft ft r, K r. :.i:::;, 'i
5a.Well Location: gg�� - I`"'+ = ' .i- 3`s I
Facility/Owner game Facility ID#(if applicable)
ft ft. AUG 1 Z023
17 it 111as /e6,, tE-i ®I 10,i ft ft. 1. f,..-resi D 7rrrese<^.:F.-2 Uttl
.
Physical Address,City,and Zip ft. ft. D1r4 Oii`.�aO G r•
....Q
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
- 7 y
6.Is(are)the well(s): ❑Permanent or ❑Temporary Si a ofC ed'91e11 Contractor Date %.,......
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with t
7.Is this a repair to an existing well: ❑Yes or InNo 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy CM
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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: .
0 24.SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: 7°3 (ft) Submit this GW-1 within 30 days of well completion per the foAowingc
.For multiple wells list all depths if different(example-3Q200'and 2@100)
10.Static water level below top of casing: 2'420 C? (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 cut.)Bit Off: 5n 1 gee 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ,/Oo.,* ';.r /
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the countywhere installed
FOR WATER SUPPLY WELLS ONLY: •
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA`
13a.Yield(gpm) Permit Program,1611 MSC,Raleigh,NC 27699-1611 y' c,
Method of test 4/^s'leo is cap � e Q�
70% hth u Date Site Visited:c6-S.-��
13b.Disinfection type: Ainonnt:_ I OZ Site Visited By: � "wee_ (Lt& I Ce44�
Form GW-1 _.._._ .. ..._.—.___.__._ North Caro1ma Dep_artmeut.of vitonmental Quality-Division of Water Resources H a 4 Revised 6-6-2018
Price: �Q !�);� per Il pc-o pe,44 -
i.