GW1--06253_Well Construction - GW1_20230925

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litiELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
0 S� 14FWATEItZONEs-7".a.1_::-c2:z7 1P-" . , as.-.:._.'?.,._� _�_._:�.. . . i
e 0'�ri®�-'f FROM TO DESCRIPTION~mot
W'jUI Contractor Name/ 3 ii ii ft, 5 ys ft ez, I IP✓"
`0.3 < 4 ft 7 ft
NC Well Contractor Certification Number :15::OIITER:CASING'(fnnmiilti=eased,wells):OR7:INEIt(it`.ap'licable)r:; :: :'al:
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATEuu.
4-1 ft. 6g ft. (;I9S in. SD/ a( pc1L
Company Name
�^.. aa�' "sS R 6iINNECASING:O&'.TIN ITHG:(geothermaldosedaap)-'-'o ,-b::.�.�_::":: �.<_._ �:
v 2.Well Construction Permit#: 01 41 ' 223 FROM _TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, ow*,State,Variance,eta) ft ft in.
ft. ft in.
3.Well Use(check well use): _ aWater Supply Well: 1I.tiS litt`7.� :1 ;`:.v_ �'7 _ 7:,2.---- "-
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,,
❑Agricultural ❑MunicipallPublic ft ft. in.
Pa
❑Geothermal(Heating/Cooling Supply) d'esidential Water Supply(single) ft ft in. V\
❑Industrial/Commercial ❑Residential Water Supply(shared) .:18 GROIITL "':2- __ - �-
❑Inigation .. i'DWeIls>100,000 GPD FROM TO �MATERT/AL - LAC.EMEpNTMETHOD&AMOUNT
Non-Water Supplyac.elil:.. lea r.`k/ L.tj ft 2.� ft. e,v+ At'Kt6ttps I �/IJNi 7''�i 1v. �4e-� -0
OMonitoring ,."' - Recovery b ft. ft if ga9 S C4 1-6)
Injection Well: e C p 2 LU23 it ft.
❑Aquifer Recharge J C OGr undwater Remediation :�.__i_._•,. P
�•1t" Q`s:.' I9:SANDIGRAVEI;•PACK'(if npplicalile)` =�_ �__.. .��_�-_._- - =i
:Aquifer Storage arn omlgsj 11 '• ' ❑ alinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test G r'( ' ❑Stormwater Drainage ft. ft
❑Experimental Technology El Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer C20DRII,7NIGZOG,(attach"aaditlona'1'slieetaifiie`ctlsary)T=.:'.'=..;7.',17-
FROM TO DESCRIPTION(color,hardness,sottureek type,grain size,etc.)
❑Geothermal(Heating/Co g Re ['Other under#21 OtherRemarks)
Date Well Started c • 'r 0 ft. (iS ft. ci ►/A Loose C1 y�-
4.Date Well(s)Completed: 1� 3 Well M# �� 53 �t.. •r. !'ti a� 7®9�'T
5a.Well Location: Phone#:3.3C-s1?V- /0 53 ft / ft �„., ,4_/ p.ey0 �4i.01
1 vozc y A;Gk1€i G y ft /ea ft. ,ir1:.Hr' V-✓` ..k, <.(a4✓`.: �/
Facirity/Own Name ]] /� ( Faciity�1D#(if applicable)
)n /02, fr' 3G O-ft. C y.g,;yt�r4/ 2,t],q/.C,••S/� ai t e:€. Aff- �
ie xi*, 1`�v, .ter'1:fr.&�� t% V ft ft.
Physic dress,City,and Zip ®r ® 'O ft. ft
`..;25REMAIKS�`.1- : r'Jµ.r._-`-V .2. .±` -.. -._.--:-�:c.- -c,".
a d.Vi k‘
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County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one le/long is sufficient) 22.Certifieatf on:
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3C o 2O(Z9 N Fro.. ..1`q sIC6 W _�� /f use
6.Is(are)the well(s): OPermanent or OTemporary S' Certified Well Contractor Date
: #Wing this form,I hereby certiify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No 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#21 remark section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeJDI'T 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 seeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ( 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: J 4 (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(g100')
10.Static water level below top of casing: / 1) (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use ' "
11.Borehole diameter: G rm.)Bit Off:tte 066 24b.For Injection Wells: Copy tb DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 r t G Y 24e.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
vt✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611 d
13a.Yield(gpm) 6o Method of test: ®q , �� a
° Date Site Visited: -23--2. _ �`.5 4 0 '
13b.Disinfection type: 70�0 hth Amount:- /4 OZ Site Visited By: ® ,', SJA.k.,• cp. 4
�y �>y>'se
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price:_ JAi- 3 \1/40