GW1--08006_Well Construction - GW1_20231214

. CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: l 3
v i t e s 5.14 W%iTF.$':ZONF.S 1.2'_'r5,it'.a' CI::.•iss' :`�'-'_`..1..: �+_: :>°:i::(:=:a.- 4 •
Well Contractor Name, FROM TO® DFSCRLPTION
S �� �ft. ���f t �a k 'place
ft ft
NC Well Contractor Certification Number • 1.15 ODTIat:CASING.'(formuIti=cased;wells).ORIANER(if'lip-llcable)'`"`.._'.:__' .T=S_Ys
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. it. 'In. tP
CompanyName -
165INNERCASING:OR.T'QBING:•(geothe'r`mal-clo`s3=loop)> �= -
2.WellConstructionPermit#: ® a'Lr (u FROM TO DIAMETER THICKNESS MATERIAL 0
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 4,./ ft. 99 ft. 6 s/,rrcin• s O PVC. (
S.
3.Well Use(check well use): ft. �1 ft in. .,
Water Supply Well: FFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .- 1
DAgricultural ' ' ❑Municipal/Pnblic f. ft in. ±
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft • ft In..❑Industrial/Commercial ❑Residential Water Supply(shared) .? .-.- -------------. --------.---._ S
❑inigation ❑Wells>100,000GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNTee
Non-Water Supply Well: O ft 5 ,7 ft 604..eilic.as
pd w
elail
❑Monitoring DRecovery ft
Injection Well: �7°ft eel. sb i�n �f el
•
ft ft b
❑Aquifer Recharge ,❑GroundwaterRemediatian r_-- •
___ _.;__� _ . .
i=I9:BAND/GRAVF.I ACK'(if:�plic`atile)�_� �__�-.._. .
DAquifer Storage and Recovery ❑Salinity Barrier FROM • TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑StormwaterDrainage ft it
❑Experimental Technology DSubsidence Control ft, ft.
OGeothermal(Closed Loop) ❑Tracer �•20:DRT>LTNGI:OG.(ittachsdditionsl"sheeteifnecessnry)a_s_2_ '-
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM ' TO DESCRIPTION(color,hardness,salllrarlt type,groin size,etc.)
Date Well Started /I-
�l$)- � fy ya° et J®.1- -
4.Date Well(s)Completed:0 7''�t3 Well ID# �1 ' yip ..n goo& d �'tt "t
5a.Well Location: Phone#: 8 2k- '3 Zel.065'$ yew` i69yft. /Pei j erev t`1
M, r,,yl.xl, ft ft.
Pe.Imot& ) 04,0I10419/ ft.
Facility/Owner Name Facility (if applicable)
&lei Alin Pi Ott Lot 10, Boon-t it 1 Q0 - ft. ft.
A M sr
Physical Address,City,and Zip at.49 O J_ ft. ft �, r °;
pt k ei �(+ 21t:REMARES w.. -_-..<:...-.._...-=-._`_`__Iii:F('-11.-_'Jul.7.12-7i
County • Parcel Identification No.(PIN) U 1,•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ U e C.,1'„-
(if well field,one lit/long is sufficient) 22.Certification:
3Ga 0-7r Ira N 2'1- 2- ?41.4 W ,
•
6.Is(are)the weg(s): ermanent or ❑Temporary Sigoa citified eHContractor 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 iKo 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#21 remarks 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
construction,only 1 GW-1's needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach'additional pages if necessary.
drilled: s (31
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: . WA? (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(g1100') CO
HI..Static water level below top of casing:
®` (ft.)
f. 24a. For All Wells: Original form to Division of Water Resources (DWR), g
) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"'
11.Borehole diameter: Z� (in.)Bit Off: 4,b 9 X 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) .
Program,1636 MSC,Raleigh,NC 27699-1636
E.
12.Well construction method: 'l 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 .�
1
FOR WATER SUPPLY'WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA jei
Permit Program,1611 MSC,Raleigh,NC 27699-1611 1
13a.Yield(gpm) Method of test: �a�! Z 9 fir 6's.lq��
o Date Site Visited: ls'id.-2-3
70/o hth oz • SiteVisitedo Cave. c L e a4s�'1
13b.Disinfection type: Amount: �� By:
Form GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2O18