GW1--06213_Well Construction - GW1_20230925

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information:
4 4 '��4an/ 310 kin %14 WATER ZONES' .. ' '.'•., •-
FROM TO DESCRIPTION
Well Contractor Name /go ft. !4 7 ft_ fg 3/7 - 3/ti
30 3 6 A lan ft. ad-! it -3® . i- 3..r6 - a® •
NC Well Contractor Certification Number :15:OUTER CASING(fo'r mult1:eased:viell4ORISNF.R gap.licahlel,_-:.:.'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL •
Company Name '
Js� `, g� G t^? 't16:INNER•CASING.OR'.IuBING(geothermalclosed=loop)"- _'_ :-r.. _
2.Well Construction Permit#: .` i -' ®e2 - Lj'L/R C— OOe34!3 FROM TO DIAMETER THICKNESS MATERIAL p
List all applicable well corstnrction permits(Le.U1C,County,State,Variance,etc.) +PR°� ft. Q// ft, g J/g in. S�� le 6.7 iL Sizt
�P
3.Well Use(check well use): ft. o ft. in. — t7 tyed 4-4a ` P
Water Supply Well: E17 SCREEi.-._.. 'i:IL:-_:-:, ,_- - ------ -. _..- _..
FROM TO D TER SLOE.SSIZE MI SS MATERIAL
❑Geoth Mural vIundenliai ft in. /y/ (
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, it m.
❑Industrial/Commercial ❑Residential Water Supply(shared) :- GROUT := : . .____ ..
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft• S/ ft 144,¢ Cemm_T/ 31 Aap
OMonitoring ❑Recovery ft. ft •/'�
Injection Well: ft. ii
ft
❑Aquifer Recharge ❑Groundwater Repiediation E,
• i i •:.,, =F +-� 1::19:SAND/GRAVEL PACK(if a`p`pIi"ca-ble)'.;, -
ClAquifeI Storage and Recovery ❑satin ty �[i`if dr L.,.a FROM TO MATERIAL 1 EMPLACEMENCMETHOD
❑Aquifer Test ❑Stormwateer Drainage
•
❑Experimental Technology ❑Subsidencdc Edntr 5 2 023 ft. ft
❑Geothermal(Closed Loop) OTracer r,..
rFf 3ltCf1 ,.,: y7 lsR! 20:DRTLIIIVGIOG(attach''s`dditiona]sheetiifiie'cessnry)
❑Geothermal(Heating/Co ling etum) ❑Other xplaillj iderr'y 4 'emarks) EOM TO DESCRIPTION(color,hardness,soillroek type grain size ete.)
Date Well Started .2 `, 0 ft 70 ft. Sv,,4/
4.Date Well(s)Completed://72 3 Well ID#44( 6 31 7U ft. I Lw ft- f_f� n , ,G��, .
ii Phone#: ft. ft f X I /�
r' 5a.Well Location:/� //��ff � //�� // 21/ 3570 Si.,yn 1 ice//° -,fug _
tgq C QA ®a s Y�L4Je [J� Nb!"��1/t '() ft. I f ft. �eil eX (�✓G,Il T Cs
Facility/Owneer��Name Facility ID#(if applicable) ft. ft.
iv, aura siLr.,+ 6.re e.1_1 16 DiC, ft. ft .
Physicalca Address,City,and Zip
AS ft. ft.
t 1 l f 5�` .7.1i REMARKS: - :.';1' . '.. =':... . ...1 - .. _ _ .7,_l..:. _.._. _ :y�� _..
County ltt Parcel Identification No.(PIN) i1 6 1�y 14, 6J it()At
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36I" >o?° 9q N 6 79° d k " W
S�//13 00
6.Is(are)the well(s):Apermanent or OTemporary i ignature of Certified Well Contractor Date
/., By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o / 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information end explain the nature of the of this record has been provided to the well owner. -t.
repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details:1
8.For Geoprobe/DPT or nosed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I G�-1 is needed. Indicate TOTAL NUMBER of wells
drilled
�/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / b (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100'
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( (ft.), Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,used'i-" 's
11.Borehole diameter: G5 (in.)glf Off: `24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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: •
n�"` 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.'Yield(gpm) / 7 Method of test: e2 4 1*- Permit Program,1611 MSC,Raleigh,NC 27699=1611
70% hth Date Site Visited: '
13b.Disinfection type: Amount: OZ VI Site Visited By: N rib •/hg fl r,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: --� •