GW1--05998_Well Construction - GW1_20230920

��.,�CONSTRUCTION RECORD (GW-1) • For Internal Use Only:
1.Well Contractor Information: I
- 7;C:14. . 01'N a l.WATER'ZONESIi.:::e l?:}::E:=___T:;:a•.: ..,.._ . _,.��_
Well ContractorN FROM TO DESCRIPTION
r7 4 ® �ft. k�9„sa ft q 1�
- �� ((
NC Well Contractor CettificationNumber 115'OUTER•C'ASING'(foi`multi=cased;w T�T 311)'ORNEI:4a"licible)i.'_::-:... • • '
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL �'
ft. ft. in.
Company Name
:16 IIQNI±RCASING.OR:'TUBING;(geotliermarclosedloop)%-i:!__ __ ' -
2.Well Construction Permit#: 3%1 a'is- FROM. TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cowtty,State,Variance,etc.) 4 lJ ft. k��y 7 ft. t/�.Y/1'.T' fp >rt PVC- C4
3.Well Use(check well use): f ft. ft. in. L
Water Supply Well:
FROM TO DIAMETER SLOT SIZE T ICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft in. ,=
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Tndustriai/Commercial • ❑Residential Water Supply(shared) - - - ---.--- -- - . . _ . _ .. ,..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 9# ft gee"„eo 7� ejeAr v
:Monitoring ❑Recovery . ft ge9 ° ft 4'0 ,avet • aerty,el 7
Injection Well:
ft. ft 0
DAquifer Recharge ❑Groundwater Remediation
• ji19:SA.ND/GRA'VEliP.ACW(ifiap'plicable).-_- - -- -----_i=.,;t2 __.___. '
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD e�
DAquifer Test ❑StommwaterDrainage ft. ft. '
1
❑Experimental Technology ❑Subsidence Control ft. ft. '
DGeothermal(Closed Loop) ❑Tracer '-::20FDRIl; IlVGTOG'(attach:•a0dilioiiai"slieatsififee-siaiy) -
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) CI Other(explain under#21 Remarks) a ft. ft. 1
Date Well Started �"-? ' jq /� 0'
4.Date Well(s)Completed:q.` �-J Well 1D# 4M-"7to o ft. cd�'ft ,/neefs le,s'd-
Pc
Phone#:3,1,-317-3041 , €ft• j/f ft , ett� .~ # cp -'1„0
Sa.Well Location: �4-. r'
/ y J Iilk Slie ka A.r ft. ft. r r %y,. ('
e�l c/v 45 L �A-1 7*i'el Pi 4r 33C-`!tI'1-9. .S'6 . ft it 1- `7-%.1'1..,.L •+r 4.. •
Facility/Owner Name Facility ID#(if applicable)
4l6.suE. C-- . 6(a1e- Omar..? ft. ft. SEP 2 9 2023
Physical Address,City,and Zip ft ft Ind r°i-t;nr-�,=,ru.:.�.o;,n
°'21•Rl.MAIIKS;�:::;..:';.:".. ::,-.:.. .3:Lb`.i- fh ,- a ,_. .._._.:.
Countye7 Parcel Identification No.(PIN) a d ��. (J�®� i;
Pee °� 6,s
e /36 ®LIc®
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6 e
(if well field,one lat/long is sufficient) 22.Certification: 9eit9 ® e,��® ® �®
3C., 3 g kS ', N cfl . O, 375. ` W 1. .
6.Is(are)the well(s): ermanent or ❑Temporary Si a of Ce ec�d Il ontractor Date
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: DYes or I!1II 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.
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)s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ( p 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �//�3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q2'00'and 2Q100')
° 24a. For All Wells: Original form to,Division of Water Resources (DWR),
10.Static water level below top of casing: 96 (fn) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 1
If water level is above casing,use"+"
11.Borehole diameter: :- 6 (in.)Bit Off: I� s 60,5 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IIJC)
Program,1636 MSC,Raleigh,NC 27699-.1636
12.Well construction method: Ayr fc4.4by 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 74
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 7.
FOR WATER SUPPLY: �OONL�l': 24d.For Water Wells producing over 1I00,000 GPD: Copy to DWR,CCPCUA
i•� 9 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) i Metho�test: Air ! re..a.4 ^ Gdi �Ck CA
0
Date Site Visited:If-I:2--2 3 �''
13b.Disinfection type: 7()�o hfh Amount: r � OZ Site Visited By: 'ban 9 ^y p r A. 6,1.1 1
Form GW-1 Qrth Camlins tena.tme,,I n Pmdro tal -Division of Water Resources Revised 6-6-2018
Price:21 ` ,
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