GW1--01608_Well Construction - GW1_20240313

,>' r.WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ' ,
• 1:Well Contractor Information: 1 1 r
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Well Con clot Name/ / FROM TO 1. DESCRIPTION q�� s
/� ft. ft. I H ` ZUt4
ft ft. ' tn;ur:r a, _
*%itfc it ....-..„-„,-,,...,.-
NC Well Contractor Certification Number ;:15;OUTER'CASIN• ids:multrcaeedwe>in)�OR•I:IlVERQd'i Itaili e .2 ^=--
Yadkin Well Company, Inc. FROM TO /.1 ftz 4DLAMETER THICKNESS MATERIAL
• - 1 ft. lib ft . 6;I9-g'in. 5D 01 � po C
Company Name
<:16i9NNER'.CASING`ORTUBING•(t;eothermal:elu+'ed=Iobp)5-_-_-_------_- ~_-='
2,Well Construction Permit#: FROM TO DIAMETERTHICKNESS MATERIAL
ATh
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft. ft. .in. P arc o
3.Well Use(check well use): ft. ft in.
Water Supply Well: =:17::SCREFS1`r:. -_ _ - —
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑�Municipal/Public ft ft. in.
❑Geothermal.(Heating/Cooling Supply) 6Residential Water Supply(single) ft ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) ------ --- = v
❑lrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT IFs
Non-Water Supply Well: ft. ft CQ
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ' e
L191:SANDIGRAVELI'AC&(ifapp1(calile)1 -----'-- ---- ------- - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EHPLACEMENTMETHOD
❑Aquifer Tesf ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
DGeothermal(Closed Loop) ❑Tracer 7.:20Z DItITiftYG'LOG(ittcclisdditional'sheetiifiiirl'sisrg):. _ _ _ _-_-_ _. -_
FROM TO DESCRIPTION(color,hardness,soil-ark type,grain size,etc.)
❑Geothermal(Heating/ ooUigelketum) they(explain under#21Remarks) t r /s
Date Well Started .`�6 _ ' •ed,, `'�� `i I,DO? y ,;., C. /ff.r. ,.k. E/ 1eel(
4.Date Well(s)Completed:p'�r In../?'(Well ID#, Vs 4 ft. ft
5a.Well Location: Phone#:7Oe1ot�g4...1.3Z ft ft.
2egr anal L-t il,el.-4 f t T.14 C.tI ft. ft
•
Facility/Owner Name �+ Facility ID#(if applicable) ft ft
3C Motet C &j Al. 10i ((her y® ft. ft
CV
• `� to rt ft
PPh�ys�ical Address,(/J City,and Zip (��.�.q, ®� _I ��i _ _ •
---
•`r1 the .0,� '-21.':RF.MAARKKS/; _---- ---`. __--_ -Q._l�-�-------- ---
•
County , Parcel Identification No.(PIN) ix.,cI 4{-?. ( t)v t t �2e.p@f l h a�`i il
5b..Latitude and longitude in degrees/minutes/seconds or decimal degrees: /"-pa R�`• wet(/j))? ri1-c K' k�/0 e2 1e��
(if well field,one latllong is sufficient) 22.Certitiea on: < F
ur `a 'i lrtr;VIE) N /itleU9 r`I�t S r.)t il�1 W / i
t� r
%cam V.1=t .s
6.Is(are)the well(s): Ith ermanent or ❑Temp orary Signer of Certified Well Contractor Date
eB siguingthisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: :flees or (` o ISA NCAC 02C.0100 or 1SA 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 alibis record has been provided to the well owner.
repair wider#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprabe/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: -
.SUBMITTAL INSTRUCTIONS
9.Total well depth bel� 1st
w land surface: 6 0 O (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3s..c00'and 2Qa 1001
DC.. 1 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 wester•level is above casing,we"� •
(in. � art,.'.,3� 24b.For Injection Wells:Copy to,,DWR,Underground Injection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i'� O t�P V 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1
(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, n NC 27699-1611
132.Yield(gpm) 0 Method of test: ice.15 9 0 ter/
70% hth (.Jr, GZ Date Site Visited: ,. Za 2_3 pie..";1"
13b.Disinfection type: Amount: Site Visited By: vV g
�' I ; �t
Font GW-t North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018
Price: - , -