GW1--05339_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: .
r 6 7 M 17) wri d4WATE1iZONES .-: :is ,...:
Well Contractor Name r�, ^ r FROM ft. TO ft DESCRIPTION
Ary
3�.5 � e V ) ft ft
NC Well Contractor Certification Number
�15.:OT7TER:Ct1SING`(for::miilfi=cased weIIs):ORZ;IIVEIt"(ifap lieable)-
Yadkin Well Company, Inc. UG 1 S ?023 . FRo7K TO DD TER _ THICENFSS 1 n•IATERIAL ` '- (1CJ1
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Company Name "�`}= f�9f yp �
,moo �I ' ,�(,R3 6:'IlAINER CASINGA&'.TQBING:(geathermal closed=loop)'i=.:
2.Well Construction Permit#: v 9 ' ( V -'`tom FROM TO DIAMETER ,THICKNESS MATERIAL
List ail applicable well construction permits(i.e.UIC,County,State,Variance,etc.) , / ft 4� ft 6 l� in. S4_.2I ,V c S
3.Well Use(check well use)i "f/ap.ie�►�4a„,comp_ (1._
ft ft ( in. l/
AlQA
Water Supply Well: ,, ^''� 7.SGRET�h1:: _ -
eSf fd le ui� FROM TO DIAMETER SLOT Sr7.F THICKNESS MATERIAL .J
❑Agricultural ❑Municipal/Prmblic ft - ft.
❑Geothermal(Beat ng/Cooling Supply) ❑Residential Water Supply(single) ft ft/ "" f
❑lndustriallCommercial ❑Residential Water Supply(shared)• :.18.:GROUT
❑Isigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: ® ft. 2 ft. LJ. /A. e s 66 y f,, /3 -.§.1:-
❑Monitoring ❑Recovery ft. ft. %r
Injection Well: ft ft
DAquifer Recharge ❑Groundwater Remediation
i.13 iSAND/GRAVEli•PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' -
DAquifer Test ❑Stormwater Drainage ft• �.
❑Experimental Technology ❑Subsidence Control ft. �''---
❑Geothermal(Closed Loop) ❑Tracer ._20:DRITAI VG L OG:.(s`ttitcii addltiiiial slieets if n yeces;ai-) _ -_ .. _.
❑Geothermal(Iieating/Coo}mg Return ❑Other(explain under#21 Remarks) FROM ft TO ft DESCRIPTION(color,hardness,soillrack trPa grain size,etc.) r
Date Well Started( , 1/ S p .� � 0 7 .1oPI9 �-
4.Date Well(s)Completed: /24/2_3 Well ID#A A P" 4 7 ft y ar ft /-/ J 6lam,�4 �.
5a.WellLocation•(Ai� '^> Phone#:� ����rH.$ ft. L ft. ® �,PsAr���`� �r).Y .26Z .l ,�
ft ft. ?
gift a;d ,,,. ® -t1r,,4y &Aim/3i/mod-, piraefYst
Facility/Owner are V n Facility ID#(if applicable) ft. ft (�
iT 2 'sg /- d.(// A
S - !k ,l RA - ft ft
I�/lam
Physical Address,City,and Zip w L ft. ft
a 1 d i1.e s a dal :21: iF.IvrAxtxc - - _ -
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:
c
36., 32. 361 ® N g0w g76W w :��r
i �-.ice 41z_
>6.Is(are)the well(s): iermanent or ❑Temporary Signature of Certified well Co clan
� By signing 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 L41Vo 15ANCAC 02C.0100 or 15ANCAC 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. co
dulled: I 24.SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: t�'(4 6 (ft.)
For multiple wells list all depths if different(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
O1 24a. For All Wells: Original form to Division of Water Resources (DWR), (1
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: Ca ( )Bit Off:Sr ''7a (( 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 _, L(, w 1
12.Well construction method: 0 pq�i'i. 'L 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the ®f� a
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed J 2
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
ppy a/f Permit Program,1611 MSC,Raleigh,NC 27699-1611 •
13a.Yield(gpm) 6 C' Method of test: "/U
Date Site Visited:'-' IT-2.
13b.Disinfection type: 70% hth Amount:_ '� Oz Site Visited By: 10 lra P c
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 G
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