GW1--01614_Well Construction - GW1_20240313

; �+�JLL CONSTRUCTION RECORD(GW-1) For Internal Use Only: _ p
S 1.Well Contractor Information: Q - ' S e n" .�1,/•r'...•. V+
Jeer (,J -{Ce1S D-4 WATERLZONES'i_2;.. =P a;: c?'"s .-1;,,. .. ,^•a-r, 2:ast -
FROM • TO .•
w u DESCRIPTION •P�r�.It A.z"L� - 01 •.. ^`Cb
Well Contractor Name �r.
�( A ft' fd® ft S 7I 4�tP.1
'1�4I ■ •
ft. ft 1 ,.,+.D,', •--`.�S4.s�r:?a 14.��: +r
NC Well Contractor Certification Number 515.Y�UIEt' MG(formniti=cased:wells).ORLINFR(if P a e)T==,:,p ,:` :i:.
Yadkin Well Company, Inc. + ` �� -THICKNESS MATERIAL
ft. ft in. sr) Q�i Q v�
Company Name .i V •.-.M 71>'.: ..""
/� p� i� �v ,S6r�IIdNERCASING:Oli:T[IBING(geotHe"rmaTclosedloop)�r_s.%� `-''•� � +i.•.�>�
2.Well Construction Permit#: .9(aJ Y�• FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. t ft , in.
3.Well Use(check well use): ft. ft in 0
Fx Water Supply Well: FROM Th To : DIAMETER SLOT SIZE TIUCKNESS MATERIIA sy;
' .DAgricultural ❑Municipal/Public ft. ft. •in
,❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. It. ih.
❑Industrial/Commercial' ❑Residential Water Supply(shared) :Sg__dato Lr'w--- ti":=--"` ^--,-- "-". L�u_— `•77 -.
❑Irrigation ❑Wells>100,000 GPD FROM TO _MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • • .0 ft. ' 41
( ft f 40te.P&. Pe V tree- {'3,6kiS
OMonitoring ❑Recovery . ft. ft. j• J
Injection Well: - • '
• ' ft. ft. I ,
DA tferRecliar a ❑GroundwaterRemediation : r __
qu, g •
• ill19 gklf.)/GRyi ti grfk(ifupplica de)L_ -�-_.._�:::= .
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM TO ' - MATERIAL. . .-. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage • ft' ft I. •
❑Experimental Technology- DSubsidence Control ft. ft •
❑Geotliennal(Closed Ldop) ❑Tracer .:20i•DRII'J13NGGIIOG'(a"ttach'sdditional'sheettif,necessary)'„---_..._--_.__._.,. _._=.
is-' .'FROM TO• DESCRIPTION(color,hardness;soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Rrsnarks) ,,�
Date Well Started / �� ft. ft• 56.{t.. . _ ._
4.Date Well(s)Completed: Ire 1 1 WeiI ID#_4 '. 'AP.— o d • Ic C) tg( ft Ci iii • -
Spa Well Location;,
Phone#: 70V-• 72'ffiaStytJ ft ft. : I ` - •
J�. GrGl�,: :R4 s le ` :' f. fb
;Facility/Owner Name Facility ID#(if applicable) ft: ft ,
: 1k .S' QL4k Pe4e^! ' 2g6C coI/ , ft ft. i ,
vi'1lr'1! T f. •
- Ppphysiical Address,City,and Zip St. ft
irLJ 1 lj11^RF.NI'ARKR,,.. -._=..._ .„7._..„- 22 .......- .. r.
ke ' i
County- Parcel Identification No.(PIN) • .
`'51i:Latitude and longitude in degrees/minutes/seconds or decimal degrees: .. i, ' '
(if well held,one lat/long is sufficient) 22.Certification:
31:)023S4,31 N if/ yoS8° 9 - w . • i, `Iaq
- Si of C rtified Well Contractor!' ' Date
6.Is(are)the well(s): [s ermanent or OTemporary t
By signing this formahereby certify that the well(s)was(were)consnveted in accordance with C
7.Is this a repair to an existing well: ❑Yes or SI o - .ISANCr1,C 02C.0100 or ISANCAC 01C:0200 Well Construction Standards and that a copy 44.
Ifthis is d repair,fill out)mown well construction information and explain the nature of the oflhLr record has been provided to the well owner. -tr.,,
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 'yoir.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.SUBMIT'PAL INSTRUCTIONS •
9.Total well depth below land surface: o (ft') Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths f different(example-3Qa 200'and 2Q100')
24a. Per All Wells: Original form to Division of'Water Resources (DWR), 1
• 10.Static water level below top of casing: • (ft) Information Processing Unit,16171MSC,Raleigh,NC 27699-1617 C.
If water level is above casing,use-"+" 1
11.Borehole diameter: (in.)Bit Off: 0�s a®13 2413.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 30
Program;1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health deparhnent of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA •-
Permit Program,1611 MSC,Raleigh;NC 27699-1611 e
13a.Yield(gpm) E0 Method of test:
Date Site Visited:C—�'2' 4 3-24.-S
. 13b.Disinfection type: 70�o hth Amount: ,3 Oz Site Visited By: 0 3-6I B
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 '