GW1--07498_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD (GW-•11 For Internal Use Only:.
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1.Well Contractor Information: I xp
®eS .4411 'D-1.4>WATER7,ONFaS•2...',21::"MiJ,..:-. .�+.1-: ii�i _a,lvir�_...__.._;.... - •
WeIlContractorName FROM TO . • DESCRIPTION
� i� ISo ftft. .i33 ft t�y� '.4�y . ` alypi-, rc
. , ft
NC Well Contractor Certification Number 1.5 0 'CASING(fucmiilli'.isasediavel i).ORIONERC(if•"s'p"licaLle)�'�;,�:::0_;:t..
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS ] MATERIAL 1 .
ft. ft in. fi
Company Name
0 60 ".7A.INNER'CASING:ORTUBING:{ge-atlier`maldosed:Io itTZ .-- _--_-�:i:.M3...;+-";'�
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Yariance,eta) I ft S/ Kd' ft /_ I/-i in• AG, ,iv f'�„e_J
3.Well Use(check well use): ft. S/ rV ft 11tTii in. ��j V�{
Water Supply Well: .7.�tlikk — __: --=rT: ---- - —_.__.
FROM TO DIAMETER _•SLOT THICKNESS' MA7L
❑Agricultural ❑Municipal/Public ' /ft /
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) /`t. fL ft in. - /J / -
❑lndustrial/Commercial id• ential Water Supply(shared) ;"18GROUT ��_ __ _ __ �_� _-;-- -- . -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMEN MMETHOD&AMOUNTT
Non-Water Supply Well: 0 ft ,23 ft e>/: �®
OMonitoring '❑Recovery ft ft.
• Injection Well:
ft. ft.
❑Aquifer Recharge 1:GroundwaterRemediation .
iil 9 AND1GRaAVELIPACKi(if:sppliVil7>:_-_ --_-_-_-__•-__ _
.--_-=. - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO' MATERIAL I;IMIPLAMc IN METHOD
❑Aquifer Test ❑Stomrwater Drainage ft it
❑Experimental Technology ❑Subsidence Control /ft ft
0 Geothermal(Closed Lop) ❑Tracer L20:DRI11iKGI:OG:(ittrichadditiimal'SLeetiifn`ecesfnry)`_=_..,_2= •
❑Geothermal(FIeatmg/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soli/rock type,groin size,etc.)
Date Well Started,e0•—n.;_ 3•• �1 / rt (, ft • Se."i
4.Date Well(s)Completed:la--2ti.-`i-g well m#44 A .-X(4 ' ft. o ft. mogul...'914, 6 1 72--
• Phone#:33(:0-. 0 � 1% C°S^'`'
5a.Well Location: ft ^bO�•it r, �� �i�d`�_ •
Qfs col(( Nt. LLe ' ( 'S`I'?4`i�birii�4.�! - ,L6o ft 3!-„ift �to'1e. Svc/ 17,0,f4J
Facility/Owner Name, Facility ID#(if applicable) '
BbLt i .,
ry�koic-'� kic+.i R(2( II'Ci WO A'-G{. f ft. ft. - • .
Physical Address,City,and Zip- n _y S ft.- ft w__ ';_: '�__•__
•
C�'.If. e,'l 1 Al
Couaty. Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ..
' (if well field,one lat/long is sufficient) 22.Certification: t l• ,.. '.• •••:•'•, ?�i;r
(e , h 7O N &f A 6 3g36 wL. %iI.D
-6.Is(are)the well(s): .Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
i _ '7.Is this a repair to an existing well: ❑Yes or to 15A NCAC 02C.0100 or 154NC4C 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. 3
repair,under#21 remark section or on the back of this form.
23.Site diagram or additional well details:
: -8.construction;Geoprobe/DPction,Daly 1 GWeI is needed. Indicate TOTAL NUMBER of wells T"or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add See Over'in Remarks Box):You may also attach additional pages if necessary.
;'
'drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well w depth below land surface:"' an (ft") Submit this GW-1 within 30days of well completion per the following: O
For multiple wells list all depths ifd ffereni(example=3(4)200'and 2Q100') •
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: : • . (ft) Information processing Unit;1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" yy - , • P.
11.Borehole diameter: (in.)BIt Off:to+pl 0 I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
®® Program,1636 MSC,Raleigh,NC 27699-1636 ;
• 12.Well construction method: At r re ira,r-ep - - 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the -
(i.e.auger,rotary,cable,direct push,etc.) I 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 CPI
13a.Yield(gpm) a I Method of test: id'e afar • Permit Program,1611 MSC,Raleigh,NC 27699-1611
s - - • - W
70% hth Date Site Visited: ,,�— �i—'Z 3 / q— 19 f
13b.Disinfection type: Amount: �'� Oz Site Visited By: V
dad,• : .
Form GW-1 F _ klosth_CarolinaDenartment of Environmental Quality-Division of Water Resources Revised 6-6 2018
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