GW1--06052_Well Construction - GW1_20230921

WE IL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
.)". _'� I
1.Wall Contractor Information:
,,A rA' ilk) I a. rt14:;WATE$ZONES.;. ,: %;? ''
FROM TO DESCRIPTION
Well Contractor Name ft. it I re i '
Ji )-°A _____--
ft. ft.
NC Well Contractor Certification Number ?15.oUTF.RCe1S1NG.(fo 'multi'cased-wells)ORLINE.12: f.ap'lic'able)'":' :r::
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERLAL
ft. ft. ' ' in. �{
Company Name r,;�--- !/
{// 16:'INNERCt15INGAR.TIIBTNG;(geotliermalclo'sedlo`o"p)','s�._ �,
2.Well Construction Permit#: g I la S'?Ce, FR _ TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) t/ft' /09ft 44A5• in'
5V 6,, 1d KC,
ft. ftin. `ems j
3.Well Use(check well use):
Water Supply Well:
F ." '=; �_ - .si °_ _' _ �' _i_ }_ir:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) presidential Water Supply(single) ft ft in. 75
❑Industrial/Commercial ❑Residential Water Supply(shared) :`-
18:
❑Irrigation ❑Wells>100,000 GPD FROM,, TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: oft a it 1 oi I. . pc&er e of
❑Monitoring ❑Recovery y ft. ?soft. J .a•�#earI a,J s
Injection Well: x tt• a� t�� ��
❑Aquifer Recharge .❑Groundwater Remediation _
i419}:SAD/GRAVEN•PACK(ifsjiplic'able)_::. r_"_x:' - : _, •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' • : i
DAquifer Test ❑Stormwater Drainage ft. ft ,](mil
❑Experimental Technology ❑Subsidence Control ft. ft t,
❑Geothermal(Closed Loop) OTracer 2•20:13111 L-YNG'I:oG`(atta'ctiadditianalsheetaifiieceisiry)- _:`_ =.:::':_+.7:c ,.
FROM TO DESCRIPTION(color,hardness,soillroek type,grain size,etc.)
14
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started/'•)6>.'5 Oft. 90' ft. s O 1 p .feime, mod
4.Date Well(s)Completed: ';1.CI•9 Well ID# 44 F-4-3 r gp.9 ft ilia it. s ��� e4 •.y
11
Sa Well Location Phone#: 70 ff• `? r-JT.2 ft ft �''^' l.� a"sa$ a `�., ,,� - i
ft. ft. " I.k�tn..r L.% k: ?., �f-I
Facility/Owner Name y O - Facility IN(if applicable) ft. ft. S E P -j 2023
9isO ftruce.. k&ie 1 , F(1t'7Gs.-Jod ft. ft _
Physical Addr s,City,and Zip ft. ft intO4Y-i''.a t:;n e"ft'I.sO4i.::2 Lines
Al i21'::RF,MARES:_ 7.:_ ._�`25:i:,_`- "l ---_�Ap_�_�/',' -'...::.._T.. :-.i :'-}
County ice- Parcel Identification No.(PIN) 5c' rU °�°tv 'tr54-s"" fi I "�n'ar 8; 'ill o ' ' ed
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6.� 7 0- So p ae 645° s de ,l otri .-5
/71,,,ll;, .4
(if well field,one lat/long is sufficient) 22.Certification:
•
w
6.Is(are)the well(s): ❑�,eirmanent or OTemporary
Signs Certified ell Contractor Date 00
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with .j.
7.Is this a repair to an existing well: ❑Yes or ill o 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction_Standards and that a copy (,,j
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 411 3 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3Q2d0'and 2 a@100�
10.Static water level below topof casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
g Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: f� (in. Bit Off: too 05"- 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
t ) Program,1636 MSC,Raleigh,NC 27699-1636 ,
12.Well construction method: ir'O 0.7 d' f 24c.For Water Supply and Open-Loop Geothermal Ret irn 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
13a.Yield(gpm) IVIethod of test:
®; Pr Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection
Date Site Visited:
type: I 70 hth Amount: OZ Site Visited By:'. Revised 6-6 2018
Form GW-t Noitb CatolinaDepartment of Environmental Quality-Division of Water Resources
Price: