GW1--07569_Well Construction - GW1_20231121

• L'cONSTRUCT11ON CO (GW_f) For Internal Use Only: , I
•
•-1.WeI:Contractor Inf rmntion:
71 1" �ID id 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name I b 0 ft, kW, ft• 6,c ' d1,,,c, .- g- 1 fi ys
3 i) 3 6 if s 2) ft• 3 zs ft. ,S7 c� �� Umiak)7- 'bets-S�A^ ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-case wells)OR LINER(if ap
YA7KJN WELL COMPANY,INC. FROM • TO �y DIAMETER THICKNESS MATERIAL
..`r ft") 1$0R 6-17i in, oat /r Gs iv .I.44.1
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
( FROM 0,o o 4 (i FROM / TO DIAMETER THICKNESS MATERIAL
Li Well Construction Permit#: rV r iri es in. 0'use, 6` � �i i,�
List all'applicable well construction permits(i.e.U1C,County,State,Variance,etc) � if2 i y ft. S 6
ft. ft. in.
3.Well Use(check well use): ,
• 17.SCREEN
Water Supply.Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural.-. • ❑Residepal/Publ e ft, fr /
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) /fr, ft. m.
❑Industrial/Commercial . , ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-WaterSupplyWell: � ft S00 ft. /l� �1 ,
[Monitoring • ❑Recovery ft. ft. f.�{y3t/u Se(/}c 4 Scoot ptr SW 4621
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmediation 19.5A1VD/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control it.
Xreothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
PROM TO DESCRIPTION(color,hardness,soil/rock type,groin sae,etc.)
❑(' cthermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n
C) ft. ft. G / .S;,,,f r gr9•r1dotf - fI'1.N L
sh,.� eOPs-23 A ¢�
4.Dare Well(s)Completed: I0-to'�� Well D#a 4 P 2-3 3 0 it. f em ft. /� 4 trill,
ery W� ;b1 cA/3 J,vrx.
81L{ ouwea a.+(�1�� `® ft. yeO ft f.8/S AOf11L LZ1flT� Z AWJ� 4
5a.WellLocation: Phone # g19-1a4-a-lu W/ oe b .„
ft. ft. ..
CG(4e C4'6 C (tes ei ft. ft' �.1r .r-6.,s ri �. 'y.. �.
Facil:.+Owner•1NaE a Facility ID#(if applicable) •
�. _
2 3ez,, e5. - "ei,i. Sc'I, .13 Lett,' a ft. • ft' NOV ? S 2023
r $ 1`I q ft A ft. _ , •
Phys.cal Address,City,and Zip
Q 21.REMARK5 t''y"'•
Cour.:y .
• Parcel ldentification No.(PIN) BORES (/ ) DEPTH ( ) 4 (.Q/l�f�iskq 1
• 5b. .•atitude and longitude in degrees/minutes/seconds or decimal degrees:
f/ LOOPS PER BORE ( I ) DIA OF LOOPS (t
(ifwrl field,one latllongis sufficient) 22.Certification: SDR OF LOOPS OR ) .elf i4
3c Cq/3c - N €sO , -zi$ ( W . / iO- (Q- 2 3
6.Is(are)the well(s): Xermanent or OTemporary
S goature of Certified Well Contractor Date
By signing this form,I hereby certij,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IINo 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
.P hrs 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. -
-7cir under#21 remarks section or on the bock of this form. 23.Site diagram or additional well details:
8.Fr:r Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
consmiction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. --
drilled; ti _PP�� 24.SUBMITTALINSTRUCTIONS
S VCY
9.Total well depth below land surface:_ .(it.)• Submit this GW-1 within 30 days of well completion•per the following:
Far multiple wells list all depths if different(example-3(g200'and 2©100')
�- (ft.) 24a. For All Wells: Original form tti-Division of Water Resources (DWR), C
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1fwaler level'ifabove casing,use"+"
11.Borehole diameter: C (in.) Bit Off: Sr ' 10 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY 99 E
•12.1Vell construction Method: m m_fA. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e...uger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOF: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) t%® Method of test: rib. •6. I S.
70%HTH oZ DATE SITE VISITED: 9 m 2,7 -2-
13b.Disinfection type: Amount: 1 Z4
Pr rlP: VISITED BY: D •• . ppp�,,,,
;,,:3 GW-1 North Carolina Department of Environmental Quality-Division of Water Reso�rces Revised 6-6-2018 y: