GW1--06973_Well Construction - GW1_20231027

WELL CONSTRUCTION RECORD(GW-1') For Internal Use Only:
1.Well Contractor Information:
.3ePi"r7 Li-304k I wS _14:WATER7.ONES`. :_=',;_____,_.�.._—____........._____:::::-,.1...- c='=''
Well Contractor Name FROM , TO DESCRIPTION
a Os- A ft. ft I
ft. ft
NC Well Contractor Certification Number :�157OIITER CASING"(for.mn]ti wedwellit)OR•LINER{ifls"'livable)==�" '
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL. - !••
ft. ft in. ‘,11)..
Company Name I:16c'INN R.CASING'OR TUBING'(geothermal aisle-1=Ioop)7"-'�-'7--------7,..------
c•
2.Well Construction Permit#: 3 B 5 SAY FROM TO DIAMETER -THICKNESS _ MATERIAL c'"
List all applicable well construction permits 7.e.UIC,County,State,Variance,etc.) 4 1 R• G 3 it L SW rn. . '1?I? 601 v r.
3.Well Use(check well use): ft ft in.
Water Supply Well:
`, PP Y P FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I/Agricultural [q {,-• e-JMuaicipaUPublic ft ft. in.
(Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in,
❑lndustrial/Commercial ❑Residential Water Supply(shared) EI8` Otil..--------- —--- --- - _ --- - ------_-._
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply 0 ft Li ft
PP Y Well: 1 Pick 1i4 _re wed J[p 3 `°o
❑Monitoring ❑Recovery ft. ft J (v
Injection Well:
ft. ft.
❑Aquifer Recharge El Groundwater Remediation LI9PSAND/GRAVEL PACK"(f sPp71cib7e)L _- - ;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. e` 0
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer :;Zp2;DRII;YBPIG'>±O:Gi(atriaeliadditiiinnhsheeti;ifae"cissarq)i=FROM TO DESCRIPTION(color,hardness,soillrook llpc,kratn she,etc.)
❑Geothermal(Heating/Coolipng Return) ❑Other(explain under#21 Remarks) o it ' 7 ft. �,
Date Well Started gr/4l'!7.3
4.Date Well(s)Completed: Yrei/)3 Well ID# I 5?9 •�I ft. .�o ft. 8C6s fpl Rock
Phone#:Ji 47'7 -A.109 st) ft. 6U.ft GC'5a Well Location: � 4 n1't'!
S et 11 l : PAP let vb. 3 3G-ate-43 y.3 ft. ft T. - T,
rc",' a
4..,v � 1 Is-w
Facili /O Name FacilityID#(if applicable) ft. it -':'"' 9 ,, te^L)
h PP ) ��. .�'I vr.
L 3 44( itiwy 8 g' �� e, Way fi 1 ft. ft OCT 2 7 2023
Physical Address,City,and p
_11 RF.M'ATrKR i..—_..-----------------_-..------ `2-----gr.-,._.:J::v-7- .;;;IZi i_r1 .S
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /M't) "AA C gl,4-- 22/r
(dwell field,one lat/long is sufficient) 22.Certification'
. • t' a 1..S N '/t 49 - 2- W
6.Is(are)the well(s):/Permanent or ❑Temporary Sign e'ofCe ifiedWellContractor Date
By signing this form,I hereby cern),that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ro ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out,Grown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remanla 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 ig needed. Indicate TOTAL_NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: G 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6t o (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
10.Static water level below top of casing: /4 kit)
) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: Co (in.) G, 01 S 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 1.4
Program,1636 MSC,Raleigh,NC 27699-1636 .67
12.Well construction method:
(i e.auger,rotary,cable direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
il
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 0
13a.Yield(gpm) NIA Method of test: *vile Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth `� Oz Date Site Visited:.a,..2.,e— 0
�
13b.Disinfection type: Amount: Site Visited By: Ve
Ferns GW-1 w North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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