GW1--06231_Well Construction - GW1_20230925

Vi r_LL°_. C ,1_1 TSTRUCTION RECORD {[r V`I_--1) For Internal Use Only:
.
I.Ws'i Contractor information: , l •
_ -3ec�cy (�a'Fk tins .14:.3VATERZONES
.. .--
FROM TO DESCRIPTION
Well Contractor Name ft, aloft. 31.6ev
a'-ISa A ft. • ft. !1 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased l'vells)OR LINER(if ap licable) `l
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS 1 MATERIAL `
ft. ft. in. C
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) 'C
2.Well Construction Permit#• d l.! IA
^^r FROM TO , DIAMETER 4-f ft. 7 ft. &IA! in. SpF THICKNESSaa � e MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.
ft. ft. in. CA
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL (>
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ekaesidential Water Supply(single) ft. ft. in. CA
❑Industrial/Commercial ❑Residential Water Supply(shared) 13 GROUT o-
❑litigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 244 ft. , µj(e PINS found R I 5
❑Monitoring ❑Recovery ft. ft. Z
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation a
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) d
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) N
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. ?5 ft. go;I
4.Date Well(s)Completed: 'f!`+l s3 Well ID# 0_4t -IS ft- 1,00 ft- G call 1
ft: ft. 1
5a.Well Location: Phone # OF-i3 0`3 lett I -
Qf u zap / ft 1.�,. _ , ,;,�.w., I-
yv `�"�l tPE, �41L��e� ��b'�s ft. ft. ~' ���' l% S-!i `f
Facility/Owner Name Facility ID#(if applicable)
TC74- Q 4(ex 8�St-3?2.-<30�'D ft. ft. , SE- 2 5 202,E
C'� CA
ft. ft.
Physical Address,City,an Zip Irlibrinai;ecn pr.-,,,,,_;-_ (1
cog. Q�LLq sZ� � Q V'',no✓ 21.REMARKS l�r!:� 1���....� r
County (� P 1 Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 [3. 1. g-s q N Y/ `tt 7m ? 1 1 Z w W 8 fi c{,�36.Is(are)the well(s): APermanent or ❑TemporarySiafied Well Contractor 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: ❑Yes or AlNo 15A 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 and explain the nature of the of this record has been provided to the well owner.
repair under 1121 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 riteded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. cc,��ll
drilled: 11 24.SUBMITTAL INSTRUCTIONS
(B
9.Total well depth below land surface: '� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 r@200'and 2Ca 100')
24a. For All Wells: Original form to Division of Water Resources (DWR), W
10.Static water level below top of casing: I S� (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"11.Borehole diameter: G (in.) Bit Off: ■d 4 t0 24b.For Injection Wells: Copy'to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) . Method of test: •al✓ J G '41 e rfli
13b.Disinfection type: •70%HTH Amount: oz DATE SITE VISITED: ' 0;tt ® )5-4[2,/tG
VISITED BY: cL. 63 /�C,,/ 1
Forni GW-1 - -, D North_Carolinaenartment_ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018i
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