GW1--07957_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: to
1.Well Contractor Information:
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Well Contractor Name A FROM TO ,�y. • DESCRIPTION, (�
NC Well Contractor Certification Number Bo ft. �' ft.--
G15:OUTEIt'CA E G(formhlti=casedfvefi).:01t. .TNRIV(itip'lica iey :.::-.7,‘
Yadkin Well Company, Inc. FROM TO, DIAMETER 3ffiCKNESS 9 MATERIAL
g ft, in.
Company Name
/J� '?16:IlDA�R�CA5ThiG OR.TIBING:(ge ithermaldosendop)'- --:_ --:� :�
2.Well Construction Permit II: 3 '(. ),r Q�3.3 FROM TO DIAMETER THICNSESS MATERIAL. ,
List all applicable well construction permits(i. . IC,County,Slate,Variance,etc.) 4.Lft 111 3 ft 6 I/ii in. �p�4 s a f ®u p
3.Well Use(check well use): ft ft in.J`�� (I Q�
Water Supply Well: iS.7':S.CREElitt='�-1~----_:�=. --- -. -, =.._u
FROM TO DIAMETER SLOT SIZE~- _-THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. In.
OGeothermal(Heating/Cooling Supply) C esidential Water Supply(single) _ ft ft. I� _.
❑Industrial/Commercial ❑((•.Residential Water Supply(shared)• — ---------
❑Irrigation ❑Wells>100,000 GPD FROM , TO MATERIAL EMPLACEMENT
Non-Water Supply Well: ,/1 ft. . 4 ft. ,Q3�-B O0 41., �,koioi (. tickle
OMonitoring ❑Recovery U ft ft. +'u
Injection Well: ft
❑Aquifer Recharge .❑Groundwater Remediation _ _ _
I:19::SAND/GRAYERPA.ClisPPl ificabie)_ — —_---:-_ =' • ..
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
❑Aquifer Test - ❑StormwaterDrainage ft ft ,.......,...'"- ,,,r- ��- �.
❑Experimental Technology ❑Subsidence Control ft .tf' /� •-��
❑Geothermal(Closed Loop) OTracer 126 DRTI NG1OG(attach:ad'diadiirheet"s:ifneceis"azxy) ---'` -
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21Remarks)
FROM TO DESCRTP7C[ON(velar,hsrdncu,soeJrocktype grub]size-,etc) _
Date Well Started Ud-/j, o 2 3 0 ft ,%3 ft. 5•�p ./
• 4.Date Well(s)Completed: [!—.1114 a A 3 Well 11314 , ,d,3 . /3 t. d c!i) R' 15,-,„Men Le: .—' frA,e1 y6 e'=691il e,
5a Well Location: Phone i z ft
�-(4 jii.e/CV
•
ft. ft
Facility/OwnerNamee Facility ID#(if applicab leret ft ft , ,.0�'•. 'i , + L!al i
L '-- .J O 1I-vc .- kEtA. 1 r4)' L W Ne. ft. ft
Physical Address,City,and Zip J '8 44 ft. ft D F t, 0 8 2(1.23
q oC(1045- :RR1VfhRTCR'a
County. • Parcel Identification No.(PIN) y r".:CIL''C: ` : ' .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
- (if well field,one lat/long is sufficient) 22.Certification: , ..
_07td--'1.6,,,---- '11-'1'4;.2-.3
6.Is(are)the well(s): ermanent or OTemporary Signature of Certified Well Contractor Date.
By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 154 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy •
' If this is a repair,fill out known well construction information a 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 form. 23.Site diagram or additional well details: ai
' 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.
drilled: C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30s.3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2@100')
7 24a. For All Wells: Original form to Division of Water Resources (DWR), r
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"+" CO
24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC) O
11.Borehole diameter:. 4 (in.)Bit Off: �: ��'eo Program,1636 MSC,Raleigh,NC 27699-1636
v
12.Well construction method: i f t �&,"s,o 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (,P
(i.e.auger,rotary,cable,direct push,etc.) d 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / Method of test: ZA W��4 7 /� 1 , 1
70% v Date Site Visited: / ^ 1 ^�.®
13b.Disinfection type: hth Amount: d 8 OZ Site Visited By: V 8
— Form GW-1 NoAh_Cazo"li�e6a�n ,r.f �ift�....e' r rk:_rJ�` _ _ -4_.. ��A � •
Revised 6-6 2018