GW1--08010_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor formation:
• R't�� �4 ;143WATEIIZONES _ -
i�- _FROM TO DFSCn1P.TION
WellConhactorNamc nqq ft. cl,�,�g� K P L_.j'G�. 2i.,
qG ID. li lilt.
n ft i!13 ft 16,54 . .fir r4-7 3T J,`� i
NC Well Contractor Certification Number 15;;OIITER C6SING(foi;mulfi cesed:SvelLi)ARI,I ER SPA er) �•'''''-'='
: .Yadkin Well Company, Inc. FROM TO / Di THI
ft. ft in. ,0009
Company Name
z
�y p '<I.6S •CASING:OR.TI1B G;(geot3icrmalel eeed-loop)=C:'.= >4iY--::a
2.Well Construction Permit#: `3�13f61+I 1 FR TO DIAMETER THICKNESS MATERIAL i
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) .p ft 1,17
'7 ft f 47g in Pie i S' 6Air a 1
ft. �+J ft G� in S1 CJ �qlA
3.Well Use(check well use): __�
Water Supply Well: ti7:7.SC1 K1�1:''» -_-_--__ -__L... __ _. .-__.,.
• FROM TO DIAMET�^ SLOT yTHICKNESS MAT
❑Agricultural ❑Municipal/Public t ft in•
tjGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft h.
❑Industrial/Commercial _ ° Residential Water Supply(shared) 18 ROUTC ._:_ _ti - .�`. ---- --_ ��_-_ - --
❑Irrigation ❑Wells>100,000 GPD FROM TO • MATERIAL EMPLACEMKNT METHOD&AMOUNT , t
I
Non-Water Supply Well: 0 ft. Q a(,� ft. it t pre,I,co re, J 1
OMonitoring ❑Recovery ft. 1 ft. (.P", fr
Injection Well: ft. ft.
['Aquifer Recharge •❑GroundwaterRemediation _ _..___ _
_t'9:SAND/GRAVEIj'PACK'(if applicalile) ? __ _.._ - ._ .
❑Aquifer Storage andRecovery ❑SalinityBarrier FROM F2 TO MATERIAL 1PLACER1ENTMETHOD - '
❑Aquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft
['Geothermal(Closed Loop) ❑Tracer G2 :DRIC.1 lGI:OG(a"tfnch'n`d •tional''sheetsidiiec-wnry)` 1 _2.:..-:.__:=
❑Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saiurock type gram size etc.)
❑
Date Well Started j !-fib- 3 /1 0 ft. '20 SO%i '
4.Date Well(s)Completed: ' �' �Z� Well ID#��j P �(�I 1 n ff 2 2Q ft
5a.Well'Location: Phone#: 33 3 320j3 j2�2yt, ri�j ft I 'P(�� a �(1ir'h i �
7r�vis, pitke,Az'� Tilt._ Ov ft. �fh� 1M�'1 dart.. pAy �e�`�77 /
' Faciility/OwnerName Q , t.4` Facility 1D#(if applicable) 3 00 ft so)_ft �r 5s7 ,SQ.,),- yea- ''
Of 0-7•'I.. ..'"l�r$�1,61,+O19 Qs a 13CVlidA Elk ft J J_ft.
Physical Address;'City,and Zip d ft. ft
�1l-a+17►VV& 1__f - _2
County Parcel Identification No.(PIN) - T-,r •2'f,
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: n: ! t1F'.
(if well field,one Iat/loug is sufficient) •'''
• 22.Certification: "n
36'. c0i1.5- N SIs76 ,A7 w iI- ao� _�1
6.Is(are)the well(s):X'ermanent or ❑Temporary Signature of Certified Conige Date
By signing this form,I hereby certify that the weil(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or slo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy `
1�
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. V
repair under#2I 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 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
/7 24.SUBMITTAL INSTRUCTIONS
ct/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')
•
10.Static water level below top of casing: 110 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
-
11.Borehole diameter: 0� (in.)Blt Off: 1s/) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: a i i r. n7 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
FOR WATER SUPPLY WELLS ONLY: ,24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27 699-1 6 1 1 Z
13a.Yield(gpm) Method of test:
70% hth • Date Site Visited: i •
-Z.
ti
• 13b.Disinfection type: Amount: • Oz Site Visited By: I i
1 ii Ulm
Form OW-1 _ A. ______.:North Carolina Department ofE_ Environmental Quality-Division cif Watei Resources Revised 6-6-2018 7.-le
Price:_