GW1--08003_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
.
1.Well Contractor Information:
CruA s-e g 4p irrie 1•t f .'.1A:WATERZONES:"cs: � x o . 11—- r? :1= r,.-2,..n;tat.�a "''p
Well Contractor Name I FROM TO DESCRIPTION . p
A OD ft. /AA ft i/ e'iA / 76—,915'-i92. 6/9y., O
NC Well Contractor Certification Number 'i'25:OUTER CASING(fdFmnjti-casedwe]Ie)AR•7MER Kiiii'7'reaa lej'..,."*•eY:w:t"7
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft ( in. II
Company Name ��
v �� J a.1GciIDIlVER'.CASIIdG'OR-TUBING'(geotheimal clwed7oo'p)�...�.
2.Well Construction Permit#: 0 p g7 LA. FROM TO DIAMETER THICKNESS MATERIALj� -
List all applicable well construction permits a.e.WC,CoJity,State,Variance,etc.) 4.1 ft. 9 LO it. i,i° 9 in. 5 ). •a,' lt'"L)
3.Well Use(check well use): • ft i ft
in.
__J _
Water Supply Well: - FROM TO DIAMETER SLOT SIZE THICKNESS `MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. , ''` _
❑Geothermal(Heating/Cupling-Supply+)vX;,,Pesidential Water Supply(single) ft ft. in. '•' •
❑Industrial/Commerciai{ +a.:,, ea h" ❑Residential Water Supply(shared) --�— --a- W.__. ------.7. _
❑Irri ation eta')1❑Wells>100,000 GPD FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply V fil:t, 1t. 1= t_ ' 0 ft 9 i ft eeklb,lealildc1 Y ,;`
OMonitoring ,„ : $eoovery + ft ft
y ;;Injection Well: 31 ,'; ,':7-;'s; ;: ,D., ft. it
❑Aquifer Recharge ,,''ivy ❑Groundwater Remediation • r
lrl9'SAD/GRA1EI PACK:tills Plicable)i_ _ . _
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑fixperimental Technology OSubsidence Control R• ft.
0 Geothermal(Closed Loop) OTracer .:20t;DRII.'C TG'`;LOG:(atta`chndaitiiiiih sheets`iLnec;i;sssiyj .`_ �-
❑Geothermal(Heating/Cooling Return) ❑ ther.(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sa;Urock typs grai/n size,etc) ~
Date Well Started I '3/4k J -' -- it CO ft $io C e-ii i S r
4.Date Well(s)Completed: 1 S/ . 4/ ?Well ID#�V"-�6(� .L� ft' e R ®f fC tAritee5i d�i°:.e al"-: der+a , �i►� i . .
Sa Well Location: Phone# 3�lo_t,��lf y fdf � e� i if ft eic &"e) 1 6'�`� 04 /et .
glearKD�n I-a --e#� 1014°C, 41i ft. /A5 ft ` )44-5/ � :� "..ef, lq,e.� •
le
Facility/Owner Name Facility II)#(if applicable) f o-5 ft. 76). ft A.,i /C' s 6��y�+ r,/ /.••.r,res,,s
��// iitILYKilquss n�J�1� ft ft
1'hysrcal'Address,City; Zip �$�aa� n ft „ .
f ��/,�y�4ad 1 `., ,y FRRMA'RIa —______ __
WI Aces ��ff
County` ' _ Parcel Identification No.(PIN)*
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) • 22.Certifies n:
•
3& 0ZK ? N 2l Zia ZOV.; W � �5` cr)/1<
'°
S' Certified Well Contractor' Date k;�.
6.Is(are)the well(s):permanent or OTemporary
` `_; .�
By ring this form,I hereby certify that the well(s)suss(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or kilo ..Y` SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and thai a copy IS
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. lk
repair wider#21 remarks section or on the back of this form. `_ .23.Site diagram or additional well details:
S.For Geoprobe/DPT or-Closed-LoopGeothermal Well's having the same ' You may use the back of this page to provide additional well construction info '
construction,only 1 GW-1 is neteded. Indicate TOTAL.NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. ��
drilled: d 24.SUBMITTAL INSTRUCTIONS 2°'
9.Total well depth below land surface: ' - (ft) Submit this GW-1 within 30 days of well completion per the following: 2 .,
For multiple wells list all depths if different(example-3Qa 200'and 2(g100)
l 24a. For All Wells: Original form to Division of Water Resources;(DWR),
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"+" •
24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC) �.
11.Borehole diameter /(din.) / 1 y`u �� Program,1636 MSC,Raleigh,NC 27699-1636
S`1����'Yt("a4 ,) 1! l i 0
12.Well construction method: fl 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed V
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
gg l' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) d Method of test: �" f '
70% hth oz Date Site Visited: 3; — a.3
13b.Disinfection type: Amount: Site Visited By: V 8
Forst GW-1 North Carolina Department of Environmental Quality-Division of Water Resource / Revised 6-6-2018