GW1--00694_Well Construction - GW1_20240125

' i ,
i LL CONSTRUCTION RECORD(GW-1.1 For Internal Use Only: '
1.Well Contractor Information: �4
t 3 c1 ?d itS rgiawATERzoNE5-1:::::.,;F`s 7- -. '_:."" .'t f.122?.7.-. iv -:-_ .•_- . c.;-
WellContractorEame FROM ft. TO)61.
_. ft n DESCRIPTION r - .
l�����- __ S 60,Y" s'th c a c?�� 5°
NC Well Contractor Certification Number 9t ft [ °�4�St I �, � ��, ��r
f15::ODTER'C ING'(formiilti-c'a'serr ovens):OR7ER:(if t "lt ellsle).=:�;:i;:.:
Yadkin Well Company, Inc. FROM TO DL9METER THICKNESS I MATERIAL
ft. ft. 1 1 in.
Company Name Jlre. �11 _ '�
'j ,ta, ry .:l16INNER'CASINGOR:TIIBING:(geotherm-'1a clnigdloop] i' _ . :µ .�..i `t"'°
2.Well Construction Permit#: .3^ 'a,g U '�!� 8"6��-� FROM TO DIAMETER THICKNESS MATERIAL l
List all applicable well construction permits(.e.UIC,County,State, Variance,eta) j.j f. �5 ft 6 Idi in.
°S-0).\ �j6't)' c kZ
3.Well Use(check well use): • ft. it in. 6) W 04
Water Supply Well: , 17.NCREEIi.== =."7`"�. .- _. "" :"_ n_,.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑M�unicipal/Public ft ft in.
•❑Geothermal(Heating/Cooling Supply) t l idential Water Supply(single) p`
ft ft in. ;,S
❑Industriai/Commercial ❑Residential Water Su• pply(shared) _18:;GROUTC-ti-,_:ss : _-j. ��`-�"'-`-'"-`�'-';%�
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MEIHOD&AMOUNT
Non-Water Supply Weil: ' 0 ft. 1 ft. d LtilodIS tA U cc \\J 1(416 iD i
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft. `i _
❑Aquifer Recharge ❑Groundwater Remediation 'i ce
t-1.9 S'AND%G AVEL-PACK'(if.applicat iii := =_
DAquifer Storage and Recovery ❑SalinityBarrier FROM , TO MATERIAL ~EMPLACEMENTMETHODT~, .ki '
❑Aquifer Test ❑Stormwater Drainage ft. ft. e
DExperimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer r.:30DRIVINGI:OG"(itta'ch'addition>il:sheetsifnec�ary)` '-"--"""
FROM TO DESCRIPTION(color,hardness,so'illrock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 1 Date Well Started I7--", 3 ft Vi�� - ft. 0 �,
4.Date Well(s)Completed:l2k' 11-�3 Well ID# s 9S ft is to ft. 51ff L ‘. y ',ct.N, 1
5a.Well Location: :,Phone Y,3-,2o7-4s-,,&9. 0 ft. Ian ft �t A,iu„ 6� .
-t�/l i/e. 0!1 �rT v
Facility/Ow rName a Facility ID#(if applicable) R A(�°� ft "f�, G L. i.55
.-c' ��"istI^r t cd Oil`rv� �`�t •),3 R 1 a 19 ft M v{I t� d i f-ty.0170 ;c....
Physical Address,City,and Zip f 1.111(? ft °'� ft .I;`=,.•. r
er �Lv '7S':RFM:dRXS V., .,....._:::.v�.r... -t �-:- - =-.._•«-L_ .`.:...._71:: • �f 1
County Parcel Identification No
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' ti
(if well field,one lat/long is sufficient) 22.Certification: JQ l
,� ._� J N 2 5 2024 :T� �: �
` (,� - f)v '�J N - , 1 e 31.8 J W //�� / < ry dis- -.'• - -
i / " JIB In,:rr;, cn r�rr.::
. '6.Is(are)the well(s): Etrermanent or ❑Temporary
Signature of Certified-veil'ontractor LA-VQy7.3.C1 Date Bit k
.By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
-,7.Is this a repair to an existing well: ❑Yes or QNo 15ANCeiC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
:phis 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 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: /
I . 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 91 (ft.)
For multiple wells list all depths if different(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 60 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ,
11.Borehole diameter: ,6 (in.)Bit Off: tA:6 i ii 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed, // i
FOR WATER SUPPLY WELLS ONLY: e� 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ko Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited:g'..fit!-2-3' S ` I'
13b.Disinfection type: Amount: Oz Site Visited By: b r I 9" �`� g
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018 '�
Price: `" a