GW1--07673_Well Construction - GW1_20231122

1 C LL CONSTRUCTION RECORD(GW-1) For Internal Use Only: : ER i• 1.Well Contractor Information: 1
•
iiii f t4-C1 (;ctve raifiNATE.zons ,,:-. `:'i_,r' it:. - .',r': ` --- .._'. W -
i 5-ft. TO76 ft '••DESCRIPTION
Well ContrQac�tor Name LL �7 I r
7J ?�- • ft ft I `'' .
NC Well Contractor Certification Number +:.E-
15::OU1ER CASING(forlmrilfi=ce'sed.weIIs):ORI�INER(iEap lic'able)�y`_.'::..•.;.-�.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
. Company Name
'416aINNER CASING:OR:TUBING: eothermalclosed=loco —•"-''""" '''i' ',c�
0 'did —71� (� S .'MAISR v: ;::.:
2.Well Construction Permit#: t''.'51`' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e. IC,County,State,Variance,etc.) 1 ft. �q ft ` ( Srin- �0 94 P''? C
3.Well Use(check well use): tt• ft v in. rY-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
.Agicultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ' ft
❑Industrial/Commercial ❑Residential Water Supply(sha'� :1718 GRODTC�_,<i= - -__ - - -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyWell: � t � f 0�i�1 rt� .-to _" 0�f �.�
❑Monitoring ❑Recovery ft. ft. 'S.'''
Injection Well: V ft. ft. �7 c
DAquifer Recharge .0 Groundwater Remediation
19:SAND/GRAVF1.PACK'(ifiEpp]icable),•-.---_-- • • .
• [Aquifer Storage andRecovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _ ' •
❑Aquifer Test ❑StomlwaterDrainage ft. _
'
• pBitperimental Technology ❑Subsidence Control ft.
i', ..
i,• . ❑Geothermal(Closed Loop) ❑Tracer C20iDRIII:INGIAG(attachsdditio'nil"she"eta if iiie si iy) __,_1:__=____
' • • ❑Geothermal(Heating/Coolina Re. .. ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,scillrock type grin size etc)
Date Well Started iO'. 4-e2.' 0 s. 1� fr. ,, s/ '
P- 7(' ft. ao ft. la -L� , . .
4:Date Wells)Completed: (0:]u':� Well ID#/ pp l �,�f f
Phone*: 13�S - Li 97.0A�1 ft. ft. g •� •
Sa.,Well,Loca/AtiioGon: ff � /f_� ����a ���1I ei el rt% S 1 '
-. . .1 .� 1-eareA V v iA S-rJS )�J ft 9 a ft. ,01ea 9 rk. re-at
D LIL Ii
` .Facility/ wnerNanie Factaty ID#(if applicable) ft. ft.
. (Na ' !T2.1 v.j kruyt-oftrAte, ft. ft _ ._, r '
Physical Address,City",and Zi ft ft
�,•,,.__.. _....._i-----.-_r._�r--•---- -- -
e
• . •• County::' ' ParcelldentificationNo.(PIN)
'Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees: } ,
•(ifwee �p�ll field,onelat/long is sufficient) ( � 22.Certification: _ '
• /6.4 . C11 N ®° OrVI3 4 W
6..Is(are)the well(s):permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lXTo ISA NCAC 02C.0100 cm 1SANCAC 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.
repair under#21 remarks section or on the back of this forin. 23.5ite 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 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. C
drilled; ��� 24.SUBMITTAL INSTRUCTIONS .di-
Submit
9.Total well depth below land surface: V (ft) this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd ferent(trample-3@200'and 2Q100) C�
24a. For All Wells: Original form to Division of Water Resources (DWR), k!
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"+"P W
11.Borehole diameter: (in.)Bit Off: C:.0 7 0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Cl i r /"a)+Q7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) r 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
pp F . Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 G L j Method of test: ?'1 zr a
70% hth Date Site Visited: 5- - 3 A- .21
13b.Disinfection type: Amount: OZ Site Visited By: i . AF.
iRp(41 Q • .Ib
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018