GW1--06975_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD(GW-1)` ' ' : For Inteinal,Use Only:- ,
1.Well Contractor Information: - l
(„paYF ti1,7;
eC C.14?AVATERZONES __-.-_ •.SF
- - ,_ FROM TO DESCRIPTION. 1 _
WallConuactorNanie i 2° ft. 'a.j ft 1®' GPM ' , , - -
aySZ A ft. ft. I .
. NC Well Contractor Certification Number 'il5r OUTER CASING-(for.multi-cared;aells-ORI;I R:(i at--11ra�7oj`- ---:_ •- —
'Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL -`.— i
ft. ft I . in. 7
.' Company Name 316iUNNERi.CASING'OR•TIIBBIG{geotheimalr'1wel46iiM5` r -'- -
' FROM TO DIAMETER
2'.-Well Construction Permit#: 8�)5 7 ��� fit- -THICICK SS MATERIAL 1 r
List all applicable well construction permits(i.e.WC,Cowry,State,Variance,etc.) �.f R• f QS ft L Ni�' ia. , I8a 6e I V
3.Well Use(check well use): ft ft. i in.
:17cSCREEPT1:'Y r _'_
Water Supply Well: FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
ai•_,'cultural ❑Municipai/Public ft ft in; - .,--.1
•Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in
VI
❑Inndirstrial/Commercial ❑Residential Water Supply(shared) CT82iGRt)l]T _--- • �+
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD Se AMOUNT
Non-Water Supply Well: • Oft 2 ft mok Pitt Poucec IS bass
Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
H39?SAND/GICAVEL°TACE:(iLspplica"b7e)_,.:.,, - 1, _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO" MATERIAL EMPLACEMENT METHOD^r—
❑Aquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer ;:Zo?;DRII;•IILIG'>oGr(attsThTadditlonn'sheeteiGnecnsary)f
❑Geothermal(Heating/Coo'ng etum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.) ._
Date Well Started 4r� J3 - p U ft gs ft 5ba
4.Date Well(s)Completed: 1,1193 Well U) /4P-,3A7 3 9s'"ft.: 3d2 ft Ge-tdir►lle `'S.�, ,-,,- " as- r
5a.Well Location: Phone#:33`► /y..1.&p* ft ft - I S -4...+'iL.:. •a q„e,?„I
(ill;� $71-e t i�g !U Tr et- f r/4 J3a-24 `1130 • ' ft ft. 0 r,T 2 7 2023
� J' Facility/Owner_rfne Facility ID-#+(if p ) ft. ft
tl� ) V gA t "�iCrek ft. ft. :c.-
/ fj4.r'::i^:rti2fIim
Physical Address,`ces/ City,and Z ft. ft
�. h. .121SRR.MABKC) y.._ .._.•,. _ '" ,/i
County Parcel IdentificationNo.(PIN) k/gA/Ls /0 i' 0 f L1/a•11 er nil. It,"11i,c iOk
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,, -
(if well field,one lat/long is sufficient) p (22.Certification: .
?/ Z�jtaDO N f ZLs 1Qio4 W �� _,
��s3
• 6.Is(are)the well(s): ermanent or OTemporary
Signs of iced Well Contractor Date
Bysigning thisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or plsTo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out blown 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. j •
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 I GW-1 i%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: 3 Oa., (ft.) Submit this GW-1 within 36 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100) I
10.Static water level below top of casing: '0 (.,„ .24a. For All Wells: Original form to Divison of Water Resources (DWR),
limier level is above casing,use"+" r' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: CI' (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636'MSC,Raleigh,NC 27699-1636 ,
i.
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co ,
Copy to the.'`•,.•,;.
(i.e.auger,rotary,4able,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
Permit Program,1611 MSC,Raleigh.NC 27699-1611
13a.Yield(gpm) 1'0 Method of test: �Y- , •T •3'' -
70% hth .Date Site Visited:,2 x_.23 - ... _ - . g
13b.Disinfection type: Amount: ; - Oz Site Visited By: Vt�•I 1
Form OW-I-- - ' — Iu""he''uns'n' '^ "'"6 fl,.irnn rental Quality-Division of Water Resources - • , -Revised 6.6-2018 0.,;
- - Price: ` 1 ` kA