GW1--00547_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I '
3+ re'•-f �74`-Eiv. Elli WA -TEI ZONES ,_._ .z,t _::�:ir._,:7_ . ,._. 'U,.t-_;;;-0.'_ t •
We1lContrAc[orN a FROM TO DESCRIPTION
��Se7 A ft. 230 ft I I/2 GPr+'�
ft. ft
NC Well Contractor Certification Number ISi;OUTER.CASING(formiilt:IiiiirieIIs):OR'LIVERVe..ap licalile)'`"_•;%;r..
Yadkin Well Company, Inc. FROM TO DLAMETER _ THICKNESS MATERIAL
ft. ft. ! in.
Company Name -_
p o :i6 INNER•CASING:OR.TUBING:(ge"otliermal clo`sed2161fu 1c. '_ ``:l. : .
2.Well Constrnetion Permit it: B�sJ FROM TO DIAMETER THICKNESS MATERIAL -'st)
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) * ft. 2W w s ft. /�/5-A, O ilL . 18 /(�G 1 V `-
3.Well Use(check well use): j ft. ft in
Water Supply Well: '- SCRE` . -.1::"�- .._;`_`:1 ._ _�=_"..r_�_-_-_--.` d
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in. P
0 Geothermal(Heating/Cooling Supply) ) residential Water Supply(single) ft, ft. in.
olndustrial/Commercial DResidential Water Supply(shared) :18 GROUTi = -•Y --7-.--`:: '-`-
•t)L•llaigation ❑Wells>100,000GPD FROM TO MATR.nm.: EMPLACEMENT METHOD&AMOUNT
. .':'''Piro-Water Supply Well: 0 ft ft “Ae Pit Poanrel 3 Ixilks
17Monitoring ❑Recovery 3 it 2ti ft Coach Groot, eu 4 j ba
.Injection Well: �(�
D ft. .ft
Acguifer Recharge ❑Groundwater Remediation __
i_19::SAND/GRAVELPACK'(ifapplicable)z .-'�-1•: ____ -_�__ 2_---- w.:_'_17:
DA4uifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD • - '
'❑Aquifer Test ❑StonnwaterDrainage ft. ft
1. , i
...t 11,peii mentalTechnology 0 Subsidence Control ft.' ft
:r`
OGuorermal(Closed Loop) ❑Tracer 20:DI Ifi NG1OG(attach additibnal9beets if.iiecaeary)
t r::f':, `,"' - • FROM TO DESCRIPTION(color,hardness,saillrack
;.•,:,'i , ❑Getithermal(fleating/CoolingReturn) ❑Other(explainunder#21Remarks) type grain size,etc.)
:'>'{'.'=:::Date'1VC!ell Started 11130 1.)j 0 k' �O ft -��c
.
'','� -. () p I ('4123 well m# IMP` �i L / ft. /9s ft. ew a
' . ,.�,4.Dte'GVell s Com leted: ,� o
Phone#:`70 /'�-322.-owl /is ft ft 14r..1'0"', ,d��nk Qorr11C
Sa•
jg�ell Location:T : j 7 , 2 Gf-q A +T
• ��V1 CiIp ft. ft.
Pam`:•,.'r--- ,c•5.. -,
Facility/Owner Name Facility ID#(if applicable) ft' :',ft rta C Le[ 1 'F i .. ".,
,i. 30 ti Z-01,3$s £ C/'t-s4®4 VVC it. ft. JAAl i ZUZ`t
• Physical Address,City,and Zip A 15 ft. ft
/.SAQa .1 0211REMARKS'_ -T ==.- ____:-145.,.zr0-_^r54,:71_?,.' is -_ - -_ 'y4.
County Parcel Identification No.(PIN) Dr'rt I:;(}(a
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: • •::,
(if well field,one laUlong is sufficient) 22.Certification:
36' 36° It "
N 31' 3e f,,j',/ W
17ly l6_3.:,--
6.Is(are)the well(s):,Xermanent or OTemporary Signatur of Cern ed Well Contractor
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with.;:r•;;;i
7.Is this a repair to an existing well: DYes or )(No 15A 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 and explain the nature of the of this record has been provided to the well owner.
repair under 421 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 GVJ 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
- 9.Total well depth below land surface: 5 .) (ft.)
For multiple wells list all depths if different(example-3@200'and 2@l00� Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original forth to Division of Water Resources (DWR), '
10.Static water level below top of casing: .S. (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+""
11.Borehole diameter: 6 (in,)Bjt Off: 4, 90y 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(RTC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: et if lib in", 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) II 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
13a.Yield(gpm) c Permit Program,1611 MSC,Raleigh,NC 27699-1611
1 �Z Method of test: etch
70% hth Date Site Visited:423 Vg 7 20-2 3 .mod 8
13b.Disinfection type: Amount: OZ Site Visited By:
/64.,„„..... b
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018 ' P
Price: • Qi +e t e.
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