GW1--06228_Well Construction - GW1_20230925

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F- _ ."'.,• / -h."1 0.,. I'$t...1* IV‘. -VA--k,-'• -... -U ',, l•.•.;i ' ' For Internal Use Oilly:
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1114SWATENZONES 4111WIllitt)'inenoritammi sTeuma litiascruarmoNarimmo......,--,,,,,,.....,,„„,,,,,..,---„,- --
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=Contractor Name ,,..,,„, , . , .. , ,. r-wit.,..rt_--r„.,---w- . 3, s_spi, * 4 ..ia ..
146 ta•-,7; '. . :.,..i.,;;_,, ,,„.
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NeWell Contractor CertifteatifinNumbetl:,:,. , .• ,...,.. ,- 'is.OUTER CASING ffor multi-oiled wells)GRUNER.(Van'licahle)'.- '.... .,...
•• PROM - ."TO ,DIA.METER THICKNESS,7:
YADKINWELL COMPANY,INC. _ .. , • • . ; .:••fc• - ft:' : in. „
Ciiiiiiany Name . .
16.1NNEICCASING OR TUBING(geothermal closed loop), . 7.' -' ',"•,'. .- C::"..
:31 i
2.Welt Coustr uctiqO,Permit#: _ , 0, ( 3 ' • •- FROM TO DIAMETER -THIC
..1. ' KNESS,,.':-IWATERIAL . .....=. '
List nstteepficabkWill Construction permits(i.e.Ella County,State,VaricmFg,eta) t 1 a 6 0 ft (p ) S'iTt:Sett. :4;;_ti.l.:t :-.. 19 1/C'. • •-.„,C,ft. . •
3.Well Use(check well use): ft -r'--"" '.. , •-","--=- ,.:,..'t,'::.--'_Water Supply Well 17.SCREEN .,•.:"--". et Z.:-.-'.. -',.':',Z",, • •,,t 7.7').'
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FROM TO DIAMETER SLOT SIZE..-_.:..:i TEICICNESS MATERIAL --)
. . CiAglictilfural OMimicipaliPublic ft ft ifl
OGeothermal(Heating/Cooling Supply) AResidentil Water Supply(single)
• ft ft. in.
I:Industrial/Commercial . OResidential Water Supply(shared) 18.GROUT •
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DIrrigation OWells>100,000 GPD FROM TO MATERIAL,:' EI'LACEMENT TIET .,, :- . - .- •
- M ori&AMOUNT
Non-Watei Supply Well: , 0 ft ft. I 'SCAil/r,P -6;( ve:px ,.-. .14$6,3
..
CIMonitoring ORecovery ft • ft. - ' '
Injection Well:
ft. .ft. ••.: '.',-
OAquifer Recharge OGroundwater Remediation .
19.SAND/GRAVEL PACK(if applicable) ••',. •-.-' •" ', -.• : "•-. .:i- '.•'•••''. •,
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL • ,' ' ,EMPLACEMENT=TROD '.".',•:`:..it's
I 1 OAquifer Test 0 Stormwater Drainage ft.
0Experimental Technology OSubsidence Control ft. ft. '''':' • ..-: ' : .,-• .: , ' -iZ:i'l•..,.",;,:', :'
- , ' - , --_ -,.,-' "":.. '.;•::, ',..?"-.-,-,'-:',-,':',
OGeotherm al(Closed Loop) ElTracer . 20.DIULUNG LOG(attach adrlitional sheetilf neceisary)..
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1 TO, j DESCRIPTION tel:11E1r,horrhoese,:sightektYPa, 'r''.41tia.,ie,'et.9.,::4;.11)
. . OGeothermal(Heating/Cooling Return) 0 Othei(explain under#21 Remaiks) .FROM
' 0 ft. 5.fr ft• S'o e. . . '`1... .. -,-• -: e V"--i••••w“:2:',.'::,-.,,_L.
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4.DateNell(s)Completed: 43-1'-•2 J •
Well ID#'44P-a_C 3' tee gaff.. • 0 ft .6
1 0 .t. ka biy-sh:;,.t- -- S9ir 4 4:,,' '.., ", '•':?.;,0
eSfi•V;Opir.,
...':..5a,Weil LOCUtibni. . - Phone iot---z 43-- 6 7-‘166 9 11,' ft. 29ft et -v.. Ori;im-ce=:- lif. d.'''',,, ----',..f 'j, ,:-•__ ' ';:s.
r'.....,i7f,•.''',','''.: Sti-v- e...'.5-',. au h's' __J__.. ,C ht.yhm 110Ales Zraat 260 ft. /420
ft' Cris' /2.tf.4.1.4 ..;:106 tabiS.
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' pacilitYlOwnerNithe ,,-- Pk'catty IC*(if applicable) COO ft '175 " rrso-h •444i' .:22'10c1,:-. ...;:::,...--_-.._:.: 2.i ::.- .., ..,,V
....9 55 .:.'Fiiv, i-Aektee:legier RA- itioy‘51-7-3.35 73s ft. 73 , ft -r-6 - gjeoei-'1.-.1 ti 02-ti-;c44, :"J' • ' '10
• , : Physical Address,City,and Zip
C14.7+0e. .eh'oete,s , ft. ft. ", -.0
,..-,L,Ji-,,_1(01,-5 e----.. 423
22,2.... 0 iii 3 -2 1.REMARKS
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County '- :1;i, :._ ` Parcel Identification No.(PIN) F,,.c.ka 1 (Jai 4- b r,.. , • eek;-,R.
0;f.,Atituqe:-a±0:1cingitucle in degrees/minutes/seconds or decimal degrees:
(if Well-04k one lit/long is sufficient) •
22:'Certification: ,.,--- -e-, r'r"'°.r-N.::"..:".,''.';',-": ::'.2' --,','":: •7'
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.....'(7"."--I''-------.^.$ 4.1 .-----E-.. 2 5 2023
Signature of Certified We Contractor Date 6.Is(are)the well(s) XPermanent or OTemporary
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By signing this farm,I hereby cerg,tliatAmgi,l(sXwirk(ilfhiTeAfisVigrgi In accordance with:;,-,-1=•,1,
7.Is this a repair to an existing well: OYes or ARD I5A NCAC 02C.0100 or 1.5A NCAGq2C.0200 oroCsiDelalon Standards and that a don'
rats 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 01 remarks section or on the back of this fonn.
23.Site diagram or additional well details: •••t,
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional we4 construction info . • .
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach addition'epages if necessary: ,..
drilled:
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24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below-land surface: I q q 5 (ft) .
...
For'mulltpleWells list all depths rdifferent(example-3Q200'and 26100) Submit this GW-1 within 30 days of well completion per"the following:
10.Static water level below top of casing: i 60 ,„, 24a. For All Wells: Original form to Division of Water Resources (DWR), •
. k4") Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ifwater!evens oh*cdsini,-iike•'!+"
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!. ..•, • 6 Bit Off: 51 I-25.::li.;Edre4ble diameter: ' 7' •.•' (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636 , " ' .,•.,
e,.: . -•-i , ••- " ',••'' , - '' • ': AIR ROTARY
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e.--...12 Well.construction methed:"._ -
- 24e.For Water Supply and Open-Loop Geothermal Return i Willi:Copy to the'-- •( ;
' .. .'6.6. ,cable,direct push,eta.) i•
;2. aukei:rotary
county environmental health department of the county'where installed
• . ' 1 ' ,•• .','- ,'•"•.-, . .'.• ' '-'i:•:,,-12
' '...`-'• :FORWATER SUPPLYWELLS ONLY:, i
24d.For Water Wellsproducing over 100,000.GPD CorPy:f61:?,WR,QPITCUA':,"
13a Yield(iPni)____0 460 I Method of test Pennit Program,1611 MSC,Raleigh,NC 27699-1611".'1:-:::„.r/..- ,',.:.'"•,",-,••-i;: •, ' . .-14. ::‘ : e?('1". , ?, '•-,,•-.',.".",:-::.'e_.;:.;- ' ., C ts1
.- - - 70%HTH DATE SITE VISITED: ?`"',1 ..?/.... . - • .,• - . 9
,. ,.,..., 'lab.Disinfection type: . „ ..., Amount: , ' 60 OZ '.,I ff://eS, ' •".c,,-.. t'..s.' '-;
pj,,' VISITED BY: _...,,. efso," • . -••',',.. ..• . '• '11) • ,•,:
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'nvitonmental Quality-Division nitirni;.,FrcnirrrpeL±.