GW1--01619_Well Construction - GW1_20240313

WELL.CONSTRUCTION RECORD(GW-11 For Internal Use Only: ,' ' .; " >1. I':'..'4--.1 (J)
1.Well Contractor Information: k'ik,?
&'in e J 1 (I .4:.Wi1 O`ZNES:.". :ta it i. :314.:it:,°.:i.'.;..'..-tia:?t':st FiG
V �'i t;,ax,:., ..t .
FROM TO DESCRIP,Tl(IP���_..__:;,_ -,..
Well Contractor Name [ ��;=;a 1� '.
Ll6 io . A • 10.57 ft. 1®Sw ft :b�.d&ii k7` '6 1 ,;ii).
ft. ft. irk
NC Well Contractor Certification Number ;t15;'OU1ER:CASING•(fn'r iiiiiV ased we li:ORL NER.(ifap"licabrar:✓ �'x✓_
Yadkin Well Company, Inc. FROM TO nmis THICEIQTSs lrraz
t / ft. O, in. /
Company Name fQIR 11.1.6f,I i s ':CASIN(G:ORT[)BING:C(geothermal'dose =ibup)» " als';
2.Well Construction Permit#: 3-150 �s FROM TO . DIAMETER THICENESS pM MATERIAL
List all applicable well construction permits(I.e.UIC,Cow*,State,Variance,etc.) t I ft 1/ ft m Sar _2( 1/2 v. CA
3.Well Use(check well use): ft. 1 ft _kill' i� �C Ns
1'
Water Supply Well: t X7 SORE 1`7r..,---, '.^_"2 .�i. •%s:, 7I .
PP Y FROM . TO D TER . SLOT 4 S , 7RIAL
❑A cultural , ❑ unici al/Public t' t in:, SJ9^
❑Geothermal(Heating/Cooling Supply) /Residential Water Supply(single) FROM/
• ft , in. C -. '
❑Industrial/Commercial ❑Residential Water Supply(shared) ~ --••--------•-��
slgi'GROUrL
❑Irrigation , OWells>100,000 GPD FROM TO MATERIAL . • EMPLACEMRNTMETHOD&AMOUNT
Non-Water Supply Well: 6` ft ,, ft 16 Gko pS 6 k'vt' j / 91 basis-
,
OMonitoring ❑Recovery .. _ [� ft. ' ft. j
•
Injection Well: •` - . ft. ft.❑Aquifer Recharge -�` OGroundwater Remediation -
I-i19 SAND'/GRAVEL PACK(If applicable): ia' '•�f,.�- •`....:
-' D s
AquiferStorageandRecovery - '. ❑Salinity Barrier FROM TO MATERIAL EMPLA METHOD ' •
�1'
❑Aquifer Test - DStornawater Drainage FROM/
ft. '
'• ❑Experimental Trchnology ❑Subsidence Control •ft. ' (ft.
DGeothermal(Closed Loop) ❑Tracer 20:DRIiL1!G'L'OG(a"ttiel i additlonalsheets.if,neceuary){ -'.'a`— 3i
'❑Geothermal(Heating/CoolingReturn) ❑Other,(explainunder#21Remarks). 'FROM To " nascRIPTION(color,Hardness,sotllracktrae grain size,eta)
Date Well Started'a°S,m 5 ''4 ft.
y,,A It. •.v."'
®t . _ y
4.Date Well(s)Completed: �r ...I-II WellTD#,f-I' -,•(�13�' ®.ft• 7 �]ft ���i' ir.l � • _ -
5a Well Location: . Phone#:___' 2, ® 76 'i 7, Icc1 ft o
�U3 �-/n S C 0+t _ Sec �ilu ✓k �•lta Mil. ...'1. J .1 ',51.,
Facility/OwnerName Faoih ID#(if applicable)' '' 6 e t 7 2 446i j 0•d al _•
k• U91t1e b {. •ftf 1 E ' D0-.11 ®i. ft y. . .
Physical Address,City,and Zip ft ft'
,3u--c i ^gig., ;}21 REMMItYra; ^ .....: • .°? •.ri--- -4
County 'Panda ldenhficationNo.:(PIN).
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wet'field,one lat/longissufficient) 22.Certification:. I;. ' __ •-. '
•• 36,E . �'� e2 6 - N AA ' `a.,: G.`.1 R' -5 `�; '` '
6/i°�)
6,Is(are)the wells) permanent or ❑Temporary. Signature of Certified Well Contractor;" Date °,
By signing this form,Thereby hereby ceraj that the well(s)was(were)constructed in accordance with
• 7.Is this a repair to an'existing well: DYes or ,i*o • 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy.y Ty
If this is a repair,fill outamown well construction information and explain the nature of the ofthis record has been provided to the well owner,. �J l
repair under#21.reenarks section or on the back ofthis form, 23.Site diagram or additional well details: ..�
S.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 additio,a1 pages`if necessary. ,
drilled: t gg-/• _ 24.SUBMITTAL INSTRUCTIONS '
• 9.Totalwell depth below land surface: l A (ft) Submit this GW-1 within 30 days of well completion per the following: __ '
• e For multiple wells list all depths tf differenf.(exemple-3Q2000'and 2®100� - • .,
tOet ' i-,
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 276994617
•
• If water level is above casing,use"+"
11.BorehoIe diameter: (in.)Blt Off: b.N�® 24b.For Injection"Wells:Copy to DWR,Underground Injection Control(I(IC)
i Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a,1 te9 7Ta t•7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the p
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 4
6
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA
l v Permit Program, MSC,Raleigh/NC 27699-1611
13a.Yield(gpm)_ A_ path i Method of test: I`) 11J f
oDate Site Visited: I Z— -/ L..
13b.Disinfection type: 70 fo hth Amount: �� OZ Site Visited By:
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
• Price: