GW1--06240_Well Construction - GW1_20230925

I
�"WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor ormah
;i5
G A tut 3cWATER'ZONS .. .,' '•, '1m1 _ ..,:. Y ' • `:: ...... r
FROM TO DESCRIPTION
Well Contractor Name
Li5, _ a48ft. oft /048e t �� ' doGPMG1eer
l/,�,�^'� ft. �(ft 1 I -
NC Well Contractor Certification Number -;35 OUTER CASING(for`rimiiltiv ased:aveIIs ORLINER'(rf. lie ii1 ;_>_...-
Yadkin Well Company, Inc. FROM TO _ DIAMETER i THICKNESS MATERIAL
ft. ft. ; in.
Company Name
°.16i NNER.CASINGORTUBING eotbermal'elosed;160 ==:_7_-<:,- �•
2.Well Construction Permit#: © S 7 61-9 FROM TO DIAMETER THICKNESS MATERIAL ®'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4 /ft. Sr� ft. I/4 in. $p�'a I / `f',
ft. ft �7
3.Well Use(check well use): in. _ �— ern••
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgucultural ❑Municipal/Public ft ft. in. ,
1 1 ❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) —V-- -- --_
❑Iriigation ❑Wells>100,000 GPD FROM T MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. YO ft C LP atO gol3 firo�`-�-7}
OMonitoring •-.-. ,.e ,---.- f.�,RecoI ery ft. ft V i
Injection Well: Z V Q L.. c eI ft. ft.
❑Aquifer Recharge 1❑GroundwaterRemediation --------
❑Aquifer Storage and Re6�re ' 2 5 20Zialinity Barrier 2 I1FR ShNIi/GRTO PACK(MA e):;: "_. - ACEMENTMETHOD~
❑Aquifer Test DStto�nrwater Drainage ft. ft
ie fl prc•C. U' ft ft.
• ❑Experimental Teclb '" ,❑Subsidence Control
DGeothennal(Closed Loop) ❑Tracer 20:DR1 iGGLOG(ottach'additional'she"etaifneceuary)t.1'_-1—_— _
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. n it. SQ /
Date.Well Started Y I( - 3 , t ! d
4.Date Well(s)Completed: "I tD Well 1D# !p p l'5 L 7' 3 ft. 1�� ft s1'1- .�i pvf-s rq,Y Qre i 1i
t. t`� 'I Phone#: l g`" <ro0 -2, s�. i 9a ft. 2&Aft Axis d a r Ql� rv-te
5a.��'ellLocation: (b� �5G,q �•�,10 �j l ft. ft d J �/
Ro it:wl�" re-J o n 9 aco� &1o1 lb,-n smy 5(tInrf e ridibio &milt
Facility/Owner Name A /� Facility ID#(if applicable) ft. ft
l . ne D r el,a veg , / �p 1•WFfe-L1,� ft. ft .
•
Physical Address,City,and Zip 1 VAS ft. ft v 7.::.::::::::-.'
v'21'sRF.T ARICStn.., -:;. :.ram., ` t.;'F.F•a s:'?i','`•:s: M�:•
J
°�f��S (PIN) $618 idtq UP �-)nc 1r.i11 is YI,PS)h5. 60&PM
��ty Parcel Identification No. �®
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f'`-A6€ � one 5 /
(if well field,one lattlong is sufficient) 22.Certification: .
3 C, (95, 2O1,4 N g i Q , , 406 L- w ' 6:-/&- 2.3
Signature of Certified Well Contractor ' Date
6.Is(are)the well(s): permanent or OTemporary
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 LVo ISA 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 it formation and explain the nature of the of this record has been provided to She well owner.
repair render#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 is needed. dicate 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: LIG 2N (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2(a3100)
I 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: f d O (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
`_ 9 24b.For Injection Wells: Copy to'DWR,Underground Injection Control(IUC)
11.Borehole diameter: (� On.)Bit Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: {^A 6 a'tt Y 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
t Permit Program,1611 MSC,Raleigh,NC 27699-1611 4
13a.Yield(gpm) C) Method of test: (A6 it T I
Date Site Visited: 3 6;,i3
° hth � 4
13b.Disinfection type: 70/0 Amount: I oz Site Visited By: v9,
I ; c� .d
Form GW-1:. - ----
North Carolina Department of Environmental Quality-Division of Water Resources' Revised fi-6-20188 • 1
Price: