GW1--07674_Well Construction - GW1_20231122

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V67EL]L CONSTRUCTION RECORD(GW-1) For Internal Use Only: .z
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1.Well Con motor Information
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FROM TO
Well Contractor Name • ESCRIPTION
r it q '14 17?ft. i 3 q ft fflpm C�
ft. ft I `
NC Well Contractor Certification Number "15:rOU•l CASING(fo"rmiiltgiffe:d:irella ORLTNERlitif 116.16) ;.= %f: _`:
Yadkin Well Company, Inc. FROM To DIAMETER THICKNESs MATERIAL
ft ft • in. F
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Com an Name —_ _ t
��i :��16:Il�IlVEFt:CA.SIIQG:OR;TQBING'(geotlie'mal:clo"sed=1ooP)'.�t-=--_____._..._�..:,_r
2.Well Construction Permit#: 01GBete.-�0►..ram/ FROM TO DIAMETER THIC I ESS MATERIAL
List all applicable well construction permits(ne.UIC,County,State,Variance,etc.) � ft. I f l ft jl 2)-' in- S®a ( e V� 6
• 3.Well Use(check well use): ft (( it t in.
Water Supply Well: r17; CxE7? »; _ _� -— -- - -- --- - - -
pP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL. _
kigricu1tural ❑Municipal/Public ft 'tt
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in. -
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❑IndustriallCommercial OResidential Water Supply(shared) r- -- -C
j:,18i:GZtOUR - - - --_ - -iZI
• ❑Irrigation • ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft a ft .' ,f`1-e s i 1 Utr€o' vs
❑Monitoring ❑Recovery ft. ft. 11 r[R gl 5s
Injection Well: I
fL ft
❑Aquifer Recharge .❑Groundwater Remediation �., _... _.._ _ _..__
I-19 SAND/GRAVELPAC&'Cif'applicable)::_�_.____ '-*-..,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD„ ni "• ;l
❑Aquifer Test OStormwater Drainage ft ft
11I1,/ Q
. ❑Expetimental Technology ❑Subsidence Control ft. ft F' y+ 2(.1[3-.
['Geothermal(Closed Loop) ❑Tracer `:.1olDRit , 1GI1 G(a'tiiiehidaitionalshee'taffnecnsaiy)4^__.2__::._= _ ,
0 Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(wlor,hardness,sail/rock typo grain size'eta)' ��i;;
Date Well Started 10-36-31 v ft 1y 5- ft re`.
4.Date Well 1�s)Completed:�Q- 3 Well ID# "°�s U �;5- ft. A( ft pi$ f �r�� Pe,1 t le
5a.Well Location: Phone#: S''�t4 �� ft ft 1i.
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n ill[ al� LEikrd4.rr4v VI`A1�.. Girds .2.)- it. 4® •ft. so(1 . .
Facili Ow Name• Facility ID#(if applitsble) Ito ft• t!( ft jC PI' 5.i41.y 9/d;-'r<d- .
"V� 1 eta .(cA, 1Tg+o� �/q-Vs((t ! (7 ft co,). ft �`1R.i 5,-,R.,/ 9,-. .,..,1e
Physical Address,City,and Zip ft o ft • .
',21:RF.MARKS:.:_ -- - - --`---. .-
/ ( A� . I+ ohuF kuA ''t 7UO-..UU. A�'SI1
County PamelIdentif�cationNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: qq���'®e ��ry�on��t���� S . t •
(if well field,onelat/longissufficient °�(O( 3,00 p t
) ��}},,�� 1` 22.Certification: (�,z
At7' l' U I n N xU ` q 3 us`t w - rJ� d 10,73(. '2 -' • ;
.... ..
6.Is(are)the well(s): cermanent or ❑Temporary Signature of Certified Well Contractor Date.
By signing this form,I hereby cent,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Io ISA NCAC 02C.0100 or ISA NCAC 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#2l remarks section or an the back of this form. . f a
.; 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info .
8.For GeoprobelDPT o Closed-Loop Geothermal Wells having the same
constmction,only 1 G 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• drilled:= 24.SUBMITTAL INSTRUCTIONS 01
9.Total well depth below land surface: 6°d` (ft.)
For multiple wells list all depths if different(example-3Q200'and 2QI00) Submit this GW-1 within 30 days of well completion per the following:
?0' ( ) 24a. For All•Wells: Original form to Division of Water Resources (DWR); :
10.Static water level below top of casing: Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617
Ij water level is above casing,use•'+"
:�!,',_., 3 Fa yam.
•• 11.13orehole`diatneter: C (in)Bit Off; 5 a "( �t 24b.For Injection Wells: Copy to DWR,Underground Injection Control(illC)
Program,1636 MSC,Raleigh,NC:27699-1636
i:-- °:;12.Well construction method: C rr Ira l lay 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
{i.e.auger.rotary,cable,direct push,etc.) f county environmental health department of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA CO
Permit Program,1611 MSC,Raleigh,NC 27699-1611 i
13a.Yield(gpm) 3 Method of test: °s air Fs����-�� w
70% hth Oz Date Site Visited: 0�
13b.Disinfection type: Amount: Site Visited By: �4, a.CI
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For GW_1 ____ ____ _ __ North Carolina Department of Environmental Quality-Division of Water Resources - 0 Revised 6-6-2018