GW1--06851_Well Construction - GW1_20231030

• "NEL][.CONSTRUCTION RECORD (GW-11 For Internal Use Only: •
1.Well Contractor Information:
CM'®LCC C� Z,S 'c PC- / , C' 4:.wATERLZONES-14::_..::a"GPI yw "::7'•.,si..- :W. :s;Lw_.:.,a r:.,•=:r:
Weil Contractor Name FROM TO DESCRIPTION /
3 -A d ft. goo tti 6,ti, 11 yJ,�i,��,,c A,a-
ft. ft
NC Well Contractor Certification Number
515::OUTER:CASING(for,i"ulti=casiid'vells):ORII1ITF.Ratap licable)'r"`c`S%a<w•'e,;=
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name .�+r ft. 61 ft `.la� in. SPA-0( Po/ US6i°INNuitCASSING:OR.T[IB)NG:(geot&ermal Clad ai5iifiry '!"� "-7,-',c'�`,i Jry. ,.
2.Well Construction Permit#: I.It 0 4 g - 0 L_, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.IIIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in
Water Supply Well: i 17iSCital)kt 1:.,=r ,-1-7 . - ` 1•
FROM TO DIAMETER SLOTST7F THICKNESS MATERIAL
❑Agricultural ❑Mnnicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) gleeesidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ;;18?GROUTIs��« _ '1�y,, M _ V
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&A-OOIINT ry
Non-Water Supply Well: T-- r '-i 0 ft a ' ft. 84,4,, eh In, IJy 1 /_ P®ac�
❑Monitoring tr. '^, .51 b,DReeovery ft. ft. �r' ►T dvs�Y'G if.. G
Injection Well: ' ' /� �� 1,4 S
❑Aquifer Recharge ft. ft.'
OCT Q V 20��❑GroundwaterRemediation r19::SA1YD%GRAVFSi7PACK(if alsicabler-_-::'ti , ;•�- =-Y";', .
❑Aquifer Storage and Recovery . ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD~�
❑Aquifer Test knIo t,«. -.::;.,., t7StormwaterDrainage ft. ft
0 y❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer r20:DR1TTiLNIAG:(attach'>idditional'sheetaifne "
❑Geothermal(Heating/Cooling R 7 .... ❑Other FROM TO DESCRIPTION(color,hardness,sailrack type,grain size,etc.)
(H g/ g (explain under#21 Remarks)_
ft.
Date Well Started /if ��V �� L ft ��Q ft ®,` I C Lco.c S; i' ,J/eaw{g
4.Date Well(s)Completed: Well II1 �J 49 e,v, fie.. f„�_�
Phone#. ft ft' _/ ` l7 ` c)^11
5a/well Location:`lL °� L [ o a �r`••, ems- T
I.JQUI�t ` FY�� � ��� /(]�ft' 0,9 ft /,®` 4•vf/ /Jva► , / p/ i J. '
. Facility/OwnerNrme ( {Facility Mt/(if applicable) ft. `� �`ft. ( - G��
fail 3/.Y�e0 '.E`'i AA G ✓1(id L _ ft. ft.
. Physical Addr ss,�Ciity,andZip ft ft
V�4 T` •
I t. G21 i2RMARKS.�1� -.1.�5 i,. .::'--_.-=7A-C-.:....�.��`/ _......_..._ ,.`..,._.'
County Parcel Identifcation No.(PM) 34)Z d-5 e% A,j -t0 /62 ,,Jos L n—/(o ?--92 2 j
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees: V c) ea- IOc . i,500.1 /•1'5 (ob- 7�� e)D/9S,Z
(if well field,one lat/long is sufficient) 22.Certiftcati : 1 00/' 'po-500 ia al
36. /3t°"L NEr.4, 6 9100
. ..2,---_______6671:::ge,(74416/P...)
6.Is(are)the well(s): permanent or ❑Temporary Si Certified Well Contractor Date
�� B going 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 ill 15A 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-1 is 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: r P-A (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: rU ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" c Q g Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: , on.)Bit Off:3,,C)9 1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
A.,...._
n 4. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1� �'''7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.)o�
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)
A tv 1
Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hthOz Date Site Visited: C 6— 2-
. 13b.Disinfection type: Amount: 3 Site Visited By: D 1 c ,_, 4
Form GW-I North Cnart Environmental Quality-Division of Water Resources, - ' - . ;Revised 6-6 2018 74�4'
• Pricer arolia Depment of� �sv- r n n '