GW1--06864_Well Construction - GW1_20231030

ALL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,;Nell Contractor Information:
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m.5 tict is _ . .
:,�14:WATE$ZONES a-....':-=:: -- -- • - - --_-- -. - --
Well Contractor Name FROM TO DESCRIPTION F
LIC/o A ( q� ft. la a. ft , 4441:42, 4,...� 344 man. lgpri.
W 3[?ft JVO it 1 t *raw"— Tail TeC4. q fr 1�'1 0
NC Well Contractor Certification Number :15."O CASDia(ffic'multi:CliAd rell#ORLIINER{ifit licsble)`r' .•.
Yadkin Well Company, Inc. �`
FROM T D THI S MAT
ft. F� ft In. /
Company Name 1 ` �'
'.16' NNER�CASING'O1CTUBING; eothermal'elos`ea leciPIL-': V -- . P
2,Well Construction Permit#: 7 eFROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.W County, ,Varirmce,etc.) 41 ft 5 Kit. b./2 sin'
5 (-` 2( rvC
(! t it,
3.Well Use(check well use): /it. 7 it / in. /
Water Supply Well: FROM TO DIAMET SLOTS TIU ESS MA
❑Agricultural ❑Municipa1Public t / ft GJI
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) l ft. ft, in.
❑Industrial/Commercial, ❑Residential Water Supply(shared) - - -- 3
;:18f:GROUT+. .:� ]:_: •��._�_a__: — ._ .
❑Irrigation -__ -.. DWells->,100,000 GPD FROM TO yMATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . - ';- ii 1 0ft. dg ft t9 Chi'/). 9Yt.t,(i7 / 1t i9 S
❑Monitoring .-. ❑Recovery ft ft
Injection Well: (W.T 3 0 ZUL3 ft. ft. ( /
❑Aquifer Recharge ❑Groundwater Remediation �3
r t'r-e I :.SAKI)/GEA PACK(ifaplicabl) __ -. -- _-------
❑Aquifer Storage an(lRecovery ,OSallIItty'Barrier FROM TO MATERIAL EMPLACEMENT METHOD .y
'_�'•� �t ft
❑Aquifer Test �- - �7Stotmwater Drainage /
❑ erimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer `_''1UiDRIF_EING'I:OG''(atfacl'ail'diiionaleslie`ets '.necess`aiy)'-_____�__-____7
FROM O DESCRIPTION(color,hardness,soLock typo,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) CI
ft.
Date Well Started q•2S- �1 Of`' Q 4-0)/ 5
4.Date Well(s)Completed: 9.24-al Well ID#M/ 1 7 � Dolt. 60 ft 1 t Chs p SQ4r,
5a.Well Location: Phone#: r�a p7 ) //t /� l -n
'�Y'� �I�� 1bU ft a%�ft ( /slid 5'W/ 14h NCI*- la.t°j4. fGai'd«.
Pe° .* �.� ems'/c em ` "( 27d ft ,k 9vt7 'A.D.) ecu�s trw
C� �©c�z Z ,,� tr-s l' 1 [ /
Facility/Owner Name Facility ID#(if applicable) `,70 it i�7, ir. 1(5 h lr OK( gob
Li 3( wit,. I eifo bine 2-
Li hem e5 973 ft. )7/ it dett- 6 if'a-
pp
Physical rty, p A f� O./i ft t ig A- ft I i 5 h.1' 1In 4 h a GGJ d.'r it- kcrd �9
Ph rcal Address,C' and Zip 't l,,w ei )�: ,
����� ;.21;.RF.MdRTt•Ca
(A 7. ,i) icy SG d- 1044,41 ._S s -�vr��-, - . —, -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I 60 ' i•
(if well field,one lat/long is sufficient) 22.Certification:
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Signature of Certified Well Co ctor Date P
6.Is(are)thewell(s): (permanent or ❑Temporary
vvv By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with �°v
7.Is this a repair to an existing well: ❑Yes or l!No 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 n formation and explain the nature of the of this record has been provided to the well owner.
repair under#121 remarks section or on the back of this form. 23.Site diagram or additional well details:
0You may use the back of this page to provide additional well construction info
8.For Gi on o 'or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,,only ly 1 1 GW 1 is needed. Indicate TOTAL NUMBER of wells IN
drilled: U/) 24.SUBMITTAL INSTRUCTIONS Cil
9.Total well depthtbelow 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-3Q200'annd2(41100D
24a. For All Wells: Original form to Division of Water Resources (DWR), F.
Static water level below top of casing: 50 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 fl
if water level is above casing,use'°+" //
11.Borehole diameter: (in.)Bit Off: 6. o S D. 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12'. Well construction method: V p t p 24c.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
r V Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 0 Method of test: et P
o / Date Site Visited:
13b.Disinfection type: 70�0 kith Amount: 1 rb OZ Site Visited By: I �;"
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Form GW-1 No Carolina Department of Environmental Quality-Division of Water_Re_snnc�P= - - -------- Revised 6-6-2018 W
Price: