GW1--06249_Well Construction - GW1_20230925

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,, 9dL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well ontractor Infoon:
. N S•�c (/e°711�i (/t) e143wATE$'ZONES n r :isslrl �u:";^'v' __r i, :�h Sfu,_._ i .'°.':°i
Well entractorName FR TO .w DESCRIPTION /,�(}
3 .. ; J ft. ft �t h'�7ei0^ t.1 v1,3 CrS De t`ire d 0§-liri yay�'y
A •«[c ft ft ;J'
NC Well Contractor CettificafionNnmher l•15:OUTER CASING•(fo3malti;eesedFweIIs)ORIANER Mali'licable)'L
Yadkin Well Company, Inc. DLAMLTER: THICKNESS MATERIAL
ft. ft C r/a s in.
CompanyName 11 / ._,..,, ,,
1 6c:INNERCASING:OR TUBING(geO iermal elwed=too iT >.....z,..t;�I:
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.LUC,County,Slate,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft it in. �'j
z7
Water Supply Well: .7:SC I Eir:.,._::-.1._:- „"T �_; , _.._. -2:-.`."_`
- -->r, .{
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural ❑Municipal/Public ft ft. in
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Conimercial ❑R• esidential Water Supply(shared) ;18 GROUT : ,7—z-' —:'� ...._ . .7 �"7:': M
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL'~�rEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft !) ft -/ ® _� —
❑Monitoring ❑Recovery ft. i/ ft. `v ev ice" V✓Z V S C`mob t"I��Jr (n
Injection Well: - _•
ft. ft
❑Aquifer Recharge _❑Groundwater Remediation .,- .
1:.r19P.SANIl/GRi1vEI,PACKlif app ca.var:mr... .-- . .=:- *.<' - :CP.
❑Aquifer Storage and Recovery ❑Salinity Bander FROM TO MATERIAL EMPI ACEMENT METHOD '
❑Aquifer Test ❑Stonxiwater Drainage ft. ft. P
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer Ir20:1ga SNGI:OG:(atta'ch atadittonallheetaifnecessary) ':�,�—""' - - ....
OGeothermal(Close g/Cop Re ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,eta)
Date Well Started Del 103[ (U� ft )(/'d�ft. L ,5f Gy/i-6(i¢ekey6. ..,,t
4.Date Well(s)Completed: L�(,e.5ITe Well ID#A Ti r- / / 0 ft. �(von ft
✓'" Phone#:5 36• Gc'- /.Zoo ft ft
5a.Well Location: t X i. •i''"': I `-mi r
S k lita r"� F V PP% U� ft. ft. F p J
Facility/Owner Z e pp j� ff p� /rFacility ID#(if applicable) ` R. ft ' S`r 2 6 L o23
2 Oo �k CX e.-T /it i`t 1C.cl "ci. ?k('/i�l([x. ft. ft InfDrAI.7k1 P.'•'::5V"'-?•st 12r .
Physical Address,City,aneZip ft. ft. DIA� `� '� -
1._
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1 v. ?1,51tEMAT KSf..__. ZITi2•:. :--�,l.',.:..'",3-7--.-... :,)r -.r 7.: .�.=.t
' - iYaak
;. ,�,�
• County Parcel ldentificationNo.(PIN) 0VI U ,J ee#-. '//t4)frtttt.. t �,'b //'s �O05 `'/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: N t B, . -` 11O. Dr/If-e a ¢to,t t i`d''t Le of
(if well field,one lat/loog is sufficient) 22.Certificati..:
9
Jb.e ICsiAZ M N Ro,‘ irlorec ° w40,,,,.-10P419-37 Dcl.
Certified Wei ontractor ate
6.Is(are)the well(s):dermanent or OTemporary
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 orl0 1SANCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy & Z,
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. 4.
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 constmction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONSTA
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@200'and 2@100')
10.Static water level below top of casing: U V (ft.) 24a. For All Wells: Original foim to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. (in,) jt Off: . t t( S 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) 06
^_ Program,1636 MSC,Raleigh,NC 27699-1636 4
12.Well construction method: t f at] .-�/ 24c.For Water Supply and Openl-Loop Geothermal Return Wells:Copy to the
(Le.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
13a.Yield(gpm) (-6'4. Method of test:41\1' Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth • Date Site Visited:
13b.Disinfection type: Amount: 11/ OZ Site Visited By: I . I
'L.
Form G'PV-1 ''North Carolina Denaztment afEnvIro aLO -uality ' 'sion of Water Resources l — 2 is6'2018
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