GW1--06856_Well Construction - GW1_20231030

L-1 WELL CONSTRUCTION RECORD (GW-1)• ,For Internal Use Only '
1.Well Contractor Inforiniation: _ -
..)40.1.S. e7
ti S• _ . FROMATERZONES _. _... :. ..__. .T -
•
.TO,_ ..J DESCRIPTION !� ��^�
WellComractorName tell-.
ft ',1 ft Sh14sIC"_ ,[r4li/ '_:' t �9,`'- V
��,� ` �' als.ft ,11_6 ft. 171ir'.-f (ik.-. I 7,4, ot
NGWeII'Contractor Cex ficatioaNutn6er .115 0 TFI CASING(for'mnl&easedweIli)ARLINFAri Ali li_' )<_. 13w1212-
Yadkin Well Company, Inc. ' • FRo7' 9 ITO
• E - I DIA7VV11iZ7ER� [ TCK7S l� Y
:_ .... . ft iti
CompanyName �16:II'iNER'C G:OATElBING(geutHeitnal`c1oH loop] -- :-: -: :;_w �
A 7' I W :FROM TO' . _ DIAMETER TRCICI ESS MATERIAL ' ' -.
2.Wen Construction Permmit#: `
Listal/applicable well construction permits(Le UIC„County,State,Variance,eta) � I ft .17_ " 6,11S 'IL .lei l al rv'
1 ft , in. '
3.WeIl Use(check well use): __ .:-_-:_::::a-,::::/ -_ - --- -^- -�
Water'supply WentFROM TO µ 'DIAMETER 'SLOT SIZE .1731 MATERIAL. • '
DAgncultural. ClMunicipal/Public fts
OGeothermal(Heating/Cboling Supply) . Xlesidential Water Supply(single) R, g, in '
I7lndustrial/Commeicial • OResidential Water Supply(shared) :i:187GRODT i__-, --__• 7j- w--- '' ___TZ-______
Oltrigation .. __OWLS>100;000_GPD' . - FROM TO. - MATERIAL _ F.MPLACEaIENTMETHOD+6_cAMOIINT
Nan-Water Supply Weth ft. 2 U it i?c hi S: -&i'c.i-ra 1'/i Q ►i455
OMonitoring ❑Recovery / f / -_.. •
Injection Well: ft. ft
OAtpiiferRecharge DGrouadwater.Remediatian i`�_ /• ' jzACE(ifnmlicahle)" _ - :- - ,-w ._�,�:�
pllgniferStorageandReoovery I7SalinityBasier FROM TO. MATERIAL EM1'IA CEMENT METHOD '
DAgtiife Test oStormwater Drainage., ft. ; ft.
pgxperimentalTechnology DSiilisidenceControl ft• ft. '. ' t"
DGeothermal(Closed Loop) DTracer C20:DRTIILNGLO'G,(3ttach adeltiifia'sheeti if.necessary)a:._.._.t_= -._---
FROM TO _ DESCRIPTION(color,hardness,saNraek type,grain sire,etc.)
OGeother nal(Heating/Cooling Return), - OOdier(explain under#21'Remarks) ft t ,
Date Well Started'
3 /��/�®
4.Date Well(s)Completed: 1.0-Lc-Z'.3. Well ID#tl%T1,_m" , _ �,a ft .9 1:1 it 61,��., yoCta. h.i.'.Ld•'
Phone#: �,: .y67= �7G: '•2 I �.2'T 1 'rve�- �
5a Well Location:
-':
tai 1 Q //�� F11uti ?'Y. it }
Pac r /'LQ Qf�Qi� (.4,4') licable) - 1::::'.:':.:1C-:1''''-
1.
FecilitWOwnerName FacihtylD#(ifapp
ft OCT 3 �-2L�23:
�515 g C Al,W 11CQ,5hciro)L\._c a l : ft
w
Ph usl -k - _ >
ys' Addr�vs,City,and,Ztp w�'T �y ry_t r, ;'I
I k S�Z1:.REMAkRKS�_,__ ._. _
..Wi o_S - /,.y 5_oa ! 10
PaicelldentificafionNo.(PIN)- S' - �4�
County .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • - - - • a
(if well field,one lat/longis sufficient) 22.Certification: _
,y
3G`0S.S �/ N 81, /�S' a' i
Signature o eitified•WeIl Coattadtoc' • • .
6.Js(are)the well(s): 'immanent or 'OTemporary - "
By signingthisform,-I hereby certify that the wells)was(were)'constiucted in accordan with_;
7,Is this a repair to.anv elating well: CYes or �1'o ISA 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 tnfornation and-explain the nature of the of this record has been provided to lhe`well owner
repair,tinder#21 reinmAs section or on the back Of this fon& ' 23:Site diagram,or additionaiwellLdetailsr
8.For GeoprobelDPT Or Closed-Loop Geothermal Wells having the same You may use the back of this page ta provide additional well construction info
constriction,only 1' W=1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in-Remarks Box)You may also attach additional pages if necessary 1;.
drilled: '- 24..SUBMITTAL INSTRUCTIONS ' .0
9:Total well depth belowland surface: I, (f') Submit this GW=1 within 30 days of well completion per the fallowing :•
For multiple walk ',and2Q100) x
p 24a. For AR Wells: Original form to'Division of Water.Resources(DWR), �
1.0.Static water llevet below toist rill,depths o of casingfferent 3.fr (ft) Information Processing Unit:1617 MSC,Raleigh,NC27699=1617 : '(�
If water level is abovecasmg:use + _ = _ s. '
® - L/4 24b.For.Iniection'Wells Copyrta DWR,Underground Injection Control(IIIC T
11.Borehole diameter: Ip- - (in)Blt Off:,.�, Q' ! Program;1636 MSC,Raleigh,NC 27699.4636. - • 1; •,,
11 Well construction method: _ )r ra 4..rx-- - - 24c.For Water Supply and'Open-Loop Geothermallietorn WellS Copy to the
Cm Aug,rotary,cable;direct push,etc:)' county environmental health department of the county where installed
'FOR WATER SUPPLY WELLS ONLY:' •24d.For Water Wells prodndng.over 100,000 oiqii.Ca`py to DWR;CCPCUA
Permit Program;1611 MSC,Raleigh,NC 27699-1611:• `. ' '. • .- , . 2i--/i t6i-'ts,,.:•.:'...-.'
13a.Yield'(gpm) .- (,5 - ._ . __Methodoftesti Os
A/./ 3 -
Date-Site Visited: �4 4
70% huh' Amount: •. oz Site Utstte
13bs Disinfection ypec _ rA y
dB ,
t'e
,, t .t` y
Yetis OW-1 �. _ North Carolina De aztmeat of Enviroraue,ntal Quality"-Division of Water Resources
Revised 6 6 2018