GW1--07948_Well Construction - GW1_20231208

"- '-WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.
1.Well Contractor Information:
o Old d eI E I.g a.4MATEIMONES'iliq is.:2:�5:v`:,;=4;`. _ r F:.:"?' _..a:..,;'=�'.c,,*,.,.x1 1�i`
Well ContractorNan (RFROM TO . DESCRIPTION Y
`� p • G5°74 ft. R3® ft e✓' ., '� S rrIA .�fh
NC Well ContractorCertificattonNumber ;:15:"Oulixft"CASING.(fbi`maltrasedwellslORT,I(BIER?(d;'splic"able):: ==">:::':ar:0 i `'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL _ X:
ft it. in.
Company Namegag,hp, g2 r.1elk. �j2. 41Fv 'i16:IIZNER.CASIN TII G;ORBING(j;eotliermal'c16se'ii=laop):;<��`-_ _�.;-: (i
2.Well Construction Permit#: 4-In 2.if'7 FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.UM,Comity,State,Variance,etc.) 4,1 ft i t ft 0.7 in- ,, )3' 1c c.Iv ib
3.Well Use(check well use): ft it •
d in / 1
Water Supply Well: .71.S:C1 E t;' �':' :.='.-�' -`_ =w _. _
:- .___- -�- {Ir'
FROM TO DIAMETER SLOT SIZE' THICKNESS MATERIAL ` f
❑Agricultural ❑Municipal/Public ft ft. in. �)
❑Geothermal(Heating/Cooling Supply) ORtsidential Water Supply(single) ft ft in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) I.C.GRbUT. -=�:-��-- • -----_ --` -
l7lnigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD"&AMOUNT
Non-Water Supply Well: e ft. „5--' ft. s70,. p-
❑Monitoring ❑Recovery 45 ft' asel d ft.• R��, i.01 �a a,
Injection Well: -
ft ft
❑Aquifer Recharge ❑Groundwater Remediation•
:19:SAND/GRAVEI;PACK-(ifaiplicable)1 --- _ • -- =�
DAquifer Storage and Recovery ❑Salinity Barrier , . FROM TO ' 'MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft '
❑Experimental Technology El Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer l:20FDR7T.L7NGZOG'(attichadditionulslieeteifneecisaiy);- ,T_= _:_ -7s
FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) t ® �
Date Well Started tzti/-,dad FWD tT / ® • 5®• aye .
4.Date Well(s)Completed:if/-?0'I Well 1D#1�` J 1m/ eft Aft Ass
•
Phone.#:Z72-Z - 392G. °- ®' , s0 -P :�
. ,5a.Well Location: ii® C:l ; tr l
QN�tY�t� c • CS51'�/- 3'a� V ®ft• 77•v,ft f'eJ /-•� P °
S r/11 v► C. ,.4-h o a ® � �j ten.:
Facility/OwnerName Facilit• ylD#(if applicable) ft. ft .`g--r' 1f 't
r A�`�JS', v� ct�'eekt L." f►0, qr1 " 4116.5 3r ft ft r;
Physical Address,City,and Zip ft. ft. G 1(Il
County Parcel Identification No,(1111) fTC) : _. 9 '. a `
ti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , __ A .... .
(if well field one lat/long is sufficient) 22.Certification: - 'J® � . •
Zir
6.Is(are)the well(s): DPermanent or ❑Temporary turc df tified Well Contractor Date
By signing this form,Thereby cethfy that the well(s)sus.(were)constructed in accordance with �
, 7.Is this a repair to an existing well: DYes or l lNo. • ISANCAC 02C.0100 or ISA NCAC 02C_0200 Well'Construction Standards and that a copy =
If this is a repair,jill out known well construction information and explain the nature of the of this record has been provided fo the well owner. . ' C
repair sander#21 remark section or on the back of this form. 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 [.71
constmction,only I G 1 is needed. Indicate TOTAL,NUMBER of wells
(add'See Over in Remarks Box).You may also attach additional pages if necessary. al
drilled: // a 24.SUBMITTAL INSTRUCTIONS p
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2®100) 3
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: p 0 0: °., .- (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 �,
If water level is above casing,use"I.,'
11.Borehole diameter: (in.)Bit Off::60 r' t 4 24b.For Injection Wells:Copy to DWR,Underground,Injection Control(flJC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ,A/k' A5kgre724c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the I
, (ie.auger,rotary,cable,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 rI
13a.Yield(gpm) 1- Permit Program,1611 MSC,Raleigh,NC 27699-1611 (d
Method of test:
70% hth B v Date Site Visited:7-3-23
, 13b.Disinfection type: Amount: 2.7 y it OZ Site Visited By: CYTI
Fomi GW-1 North Carolina Department ofEavironmental Quality-fivisinn.ef_Water Resources_ __ ___ _ Revised 6-6-2018
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