GW1--01639_Well Construction - GW1_20240313

/ �I,CONSTRUCTION RECORD(GW-1) For Internal Use Only:
, I.Well Contractor Information:a B p 1
a d"�l�_ , 11I I o, t �0 `9Q 5 141;Wi1TE$FZONES'':: ';:.,s .:t;.:C.: .:':.:;r''
Well Cant acttoY'Name/� FROM • TO . ' ,DESCRIPTION
4 5 6 6 -A rt. ft t o ci
NC Well Contractor Certification Number ! 1 lC ft , ft a �a
t35:Ou J.ER CASING'(fox mu]ti cases.."alto':ORIINER(i1:'aPPlivable;�'ti
Yadkin Well Company, Inc. 'FROM I To I DIAMETER , THICKNESS MATERIAL.
Company Name _ e
116.INNEICCASINGOR.T[IBING(feottiermaleloseiilo :-+'--.:::::.:::;:
FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: 26 2 2. !®9 J -Jr.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) "ife) ft 9 0 ft (7 f in. 'PI--2-1 P VC._ (
3.Well Use(check well use): ft ft in. ..)
Water Supply Well: i:1?tSCJitEF•W.:.1_._. •,J. - s� ._..�__- ^_r ___- `'," ram:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ___
❑Agricultural ❑Municipal/Public • ft. ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) r i8'?GAbbTC�=-w--- T-`_ `--" "` `"' "--- - -'
❑Irrigation ❑Wells>100,000GPD FROM TO MATERI EMPLACEMrENTMETHOD&AMOUNT
Non-Water Supply Well: , 0 ft. 2-1) ft, fLw2 4ema 4-t Q O D da®PS 1 lcA I 5
❑Monitoring ❑Recov • • ft. ft ,
Injection Well: ft. ft. T `" i
❑Aquifer Recharge ❑Groundwater Remediation T iVr
1.19 SAND/GRAVES PACIK(if�applicab"le)':7 __�__.:::1_Mr i-..-:)0 jri ' ..
❑Aquifer Storage and Recovery ❑Salinity Barrier .FROM TO , MATERIAL EMPLACEMENT METHOD
•
❑Aquifer Test ❑StormwaterDrainage ft. ft. in;Li7rt;3•i;F;1 Pr-^.5;,,;;r; l ii
❑Experimental Technology ❑Subsidence Control ft. ft isi 4'D
❑Geothermal(Closed Loop) ❑Tracer . 2U DI23 P51VGI:OG(attach'is'riaifion$isheets:ifiablisar`p)?_'"'_,=- ���7w �'.
OGeothermal(Heating/Cooling Return) 0Other FROM TO DESCRIPTION(color,hardness,soilirock type,grain sac,etc.)
(H g/ g (explain under#21 Remarks) ft. ft a
Date Well Started Cl/ '0'L -7-� Cq 0 i OTT-T-
4.Date Well(s)Completed:®i"01"2,4 Well ID#4,Ay " / �(a .� e ft. ® ft 1 � '( i 0 �
5a.Well Location: Phone#:3 t 1 B-,79cr 3 u, ft 5 0 ft Ill I`Cet t 4:4• � k
Ark a1rQlu1 /' t9ri"Elv2tI '- S i, ft. b 90
ft. JIMerPsA.P"e l'vir A Ail'g$wl
Facility/Owner Name Facility lD#(if applicable) • a)(3, ft !0 ft `p-e sa•�', fib f' -1' /•P• t✓7'9-- r i a f f
i f 9 Coe id;a s-ih.,,4-1 ot2, Keefe e vJ.dial 7(6 ft. l Zo ft P494.4.ice. 1../ a :�C I
Physical Address,City,and Zip 0/1 4 J6 i i 1'2,g ft. i 1 I ft c(�k CO �,v n,��/f)6�k
CA: 6
County • Parcel Identification No.(PIN) -
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) / ertifi ation: 11:
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p ® �9V-i N Ro, ®I 20S> w ' A ,, •o• 1 -o3 -a
0.
6.Is(are)the well(s): permanent or ❑Temporary •gnatre ofCertiti Well Contractor Date
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 M0 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#21 remark section or on the back of thisforn,. 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.
wed' ! 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Qa 100)
b <dr) 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 water level is above casing,use"+"
11.Borehole diameter: 6 cm.)Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a u 04--Or v24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger;rotary,cable,direct push,etc.) county environmental health department of the county where installed
7
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 �s8 �, i
13a.Yield(gpm) Method of test: r `
Date Site Visited: $'-3);`�-� U
13b.Disinfection type: 70% hth Amount: Oz Site Visited By: � �! �70`�� /�°�'1�' AU,-
c9,.9la 6^ o
' Form, GW-i- ----- -------- -- --- t• - '- '"- `"E.Fmriramnental Quality-Division of Water Resources Revised 6-6-2018 .�.
Price: I - ig-