GW1--06243_Well Construction - GW1_20230925

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ALL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
(A 1/14.......*".-- 114:.WATERZONES 1:'.";__:i ,1_:_3l 2::': - __: F�i";t• t:�`_-._.._,.:.._ .._.._
Well C�ha°c�to""[�Name
FROM TO DESCRIPTION
Contractor
/asd ft 2s I ft . Si lAritdrt- `J11Gr14e/ s,9pi.
NC Welli Certification Number 'Pis f R. L/` ft. l{/^!�:G G/sir SZ 1+✓i�h 1 fOw S��►
�.15::OUTERCASING(foimulti=cased.ii'efl)ORLINERV.ap-lic"able)•r ""' _,i:;:,_.:
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERLII.
ft. ft. in.
Company Name 161INNER CASING ORt:TCBING:(geothernial clok'd loop)';,'`° ' : _.: `":
/� /
2.Well Construction Permit#: 0 0 ),(% `.4 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) `ft. 617 ft t 1 a s'n- Sd i 2 j PVC
3.Well Use(check well use): ft. ft. P in.
1 Well: Z.171.WAP:ka .^;>;:�-,r',-._:.:.�cil '.>' .::::7.:2: - _ V-'_` 0
Water Supply y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL J t�
❑Agricultural ❑Municipal/Public ft. ft in.
OGeothermal(Heating/Cooling Supply) tillesidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)• I8'GROUTs2 iC"s S': :...•, ,; - - _
❑Irrigation ❑Wells>100,000 GPD FROM , TO MATERIAL, , EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. ^ r ft ig Cs,.p s 9rcy! ( bay S
❑Monitoring ❑Recovery ft. q� ft
Injection Well: ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation i7,19:SAND/GBAVEL PACK(if applicable)t;i)t` ," --_____"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM . TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonuwater Drainage ft. ft -
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer '.2O1-DBTt1 INGtOG(itta'ch'idditiona7sheetaifheeessary)`', .:`._=._, "___v_ ..
,-
0Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,solllrack type,grain she.ate.),.
Date Well Started if-:Z5- Z' Q (9 ft q® ft. ,s--0';/
4.Date Well(s)Completed: 6 aI2S Well ID#,,-,4 ' 7 7 S (1-0 ft 3Gd ft ,fofkr �j4,,t1...,.� '5O -'
Phone#: 76-a'—E4 d . '0.+6�..,jOOft. Igo ft. (,r! ,- f j • • •,'
5a.WellLocation: (� I�7II♦ {/��+i GJ fps
., .. . .. ,
VA 04�f y m ®�e,(1; LSc ft. SOZ it d4,k. .f... ,rp,-+ . -. .
Facility/OwndrName a P� Facility ID#(if applicable) ft. ft.
f 'i.0 1,-/W14 L, 4 it --/-1-`F d2 Rd ft. ft.
ft. itPhysicll Address,City,and Zip
' ,c.21:: ,31,, ,: -.:''t:�=a:-117 :tri—N.......i�d.• V1'-' -a// t r i ti.., a.J'0....i 1f.1 County Parcel Identification No.(PIN) • c C .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `!L P "� 2023
(if well field,one IaUlong is sufficient) 22.Certification:
i'e a..1 79.7 N k1 ..V, 4& w V;.,C.,12.0t v
6.Is(are)the well(s): IJlrYermanent or ❑Temporary Signature of Certified Well Con tor Date
ddtt„ 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 Io ISA NCAC 02C.0100 or ISA 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#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-l.ispeeded. 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: SD dL (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd8erent(example-3Qa 200'and 2@1000')
10.Static water level below top of casing: 20 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), ` '
If water level is above casing,ttse"+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
•11.Borehole diameter: C (in.)Bit Off: 6 ,Q- . 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
J Program,1636 MSC,Raleigh,NC 27699-1636 6
al
12.Well construction method: 0 2 9 v AB 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e auger, cable,direct push,etc.) county environmental health department of the county where installed i
Ght a,,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA a
(gpm) Permit Program,1611 MSC,Raleigh,NC 27699-1611 ,
13a.Yield Method of test: /A� c
70% hth Date Site Visited: { 2_3� �' - 2.. W
13b.Disinfection type: Amount: 1 a OZ Site Visited By: VIA
. ,,.....--- f 1,, 0 0 `Alitrc YMt'Or-
Form GW-1 North Carolina Department o fEnv_jronmental Quality-Division or Water ources I (� Revised 6-6 2018
Price: • - . ..
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