GW1--06846_Well Construction - GW1_20231030

a CONSTRUCTION RECORD (GW-11 For Internal Use Only:
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;" �W Contractor Information: . -
::!:,,, ',. ---!...e.:',7,-C_______.,_r_case-de-'47'J :r].4::WATE$7.oAES .'.,i:�"Y't 1: :•':• ��.:;..�" -s p��
• FROMTO DESCRIPTION
Well Contractor Nam D ft. y to ft j(7b��C c - t
3o3 '-if ft ft. u� I r .
NC Well Contractor Certification Number :.;1540TJTE11.CASING(fa-iiiiilti:ei sedivreIIs ORT.INER(ifap liElble)i: 'T:
Yadkin Well Company, Inc. FROM TO - DIAMETER THICKNESS M�TsRTaT. 3
et! ft. 91 ft 4,695, in. SPR-a 1 ,(J1 ,»
Company Name /
ik16iI1VNII2CASING OR�.TIIB]NG:(Rebthermaldosed-loop)'�,::'t;5.11t;,,':3:-'.Z,e.:�-�:i.
2.Well Construction Permit#: Cal' C.2 - 2-®2- 3 FROM , TO _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) ft. ft. in.
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3.Well Use(check well use): ft. ft. in. QJt+
_f.,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL~
❑Agricultural ❑Municipal/Public ft ft in.
0 Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
❑lndustrialiCommercial ❑Residential Water Supply(shared) _ ;- .- --z:_- -s= ;� ,,1
18 GROITfiS"i.. '.. _ '•[': -41 .
❑lmgation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply. el ----, --' -••- _''''}� 4, ft. 9,5 ft .1 ®i7t•%4, iJ;da i• /c., G-e.
❑Monitoring l • t,�.0._'k.. .yr,7 URe4ozlery ft. ft. . S 11/a (S!.,Li. gu s
Injection Well: ft. ft.
❑Aquifer Recharge O C T 3 0 Z02DGroundwater Remediation „+w
119:'SAND/GRAVEL'PACK(if applic'able)7;. - _.,_ram.:.'•:�'2,._ .s J "'<;:.^._ .
❑Aquifer Storage and Recovery ❑SallnitAyBarrier FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Test 1ft:,"i'`"' m f .s , DStormwater Drainage ft. ft.
❑Experimental Technology El Subsidence Control ft. ft.
OGeothennal(Closed Loop) OTracer !::•20:DRILLSIVGT:OG.(attacti idditionilsheetsifiiiel saiWVIS s--�`-`..�-`: ' :::'=
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type Brain size eta)
Date Well Started a O ft. �69 ft. St),1/1 6 4"�,� s' t i.--e.
-.4....i.---.4....4.Date Well(s)Completed:el).0-93 Wellm# AAP p Q()L@ l 6 f- 8.5 ft. Le/S Lay5 `,410/`^JtG"'t'
Sa Well Location: Phone#:7� - Sao"' . 17 ps ft. ft. /Moe(l ` 6'. -Y, /,4 rd 7 '/ -r
sk 92,m1,P A d®C? ft. �p 2 ft. 40e_A G.c..y tsS 4!may 411,7/e /" '+�/
Facility/Owner Name gg Facility ID#(if applicable)p l� t� ft v a P ft / o c/S/7 L e-Y'frs G e^$ III .'k /k
J ®4 ,S laqrf'lI tt.1 V'1Qd&`trii-a �d li1ei ) ft. ft.
Physical Address,City,and Zip 1 rah ft. ft.
v2vRF,MARTf C�-;, .,:i_; ::-=i' A;.=c.2:a
County Parcel Identification No.(PIN)
14yCfra rG( O( f , .,'1700(prt 700pf'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 7.' ����Sf
(if well field,one lat/long is sufficient) 2.Certification: f
6.Is(are)the well(s): [ rmanent or OTemporary
Signature of Certified 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 Ile ISA NCAC 02C.0100 or I5A 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-1,needed. 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: [!? (fh) 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: W% ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ft'If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6. (in)Bit Off: l L 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
1 t p a Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4 r... a*Ila.ry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
r 2-
FOR WATER SUPPLY WELLS ONLY: G
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPTUA
41 Permit Program,1611 MSC,Raleigh,NC 27699-1611 A 1 i
13a.Yield(gpm) -1 Method of test: CA c / W�Ff�q yyt "
70% hth Date Site Visited: -9' i2. 4� - is
. 13b.Disinfection type: Amount: 2 1 OZ Site Visited By: ntiD5,
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. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 6-6-2018
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