GW1--01680_Well Construction - GW1_20240315

,•!WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Lici .eJ (AG,.I 1 I.
!,�Q%1 WATERZONES �:.a :9:,R ,p,3Sff`�... .-i ��..:.e;`:>'s>�•::Il.':.:. am
Well Contractor Name FROM TO DESCRIPTION
�— 67,i .47� ft ldc�Il ,,--�✓ f :3 5,�,p Q
lh ft .: ft i11
NC Well Contractor Certification Number
F::'OUTER.C1AS] G`(fo%m ptVelfsed:Wells):ORLIINEI.,(S sp'•li e)T) .__;:•' 4•
Yadkin Well Company, Inc. TO/ C/�S
�t. ft . u. / ,ft.
CompanyName r, , 1,�
''� :-16 IlHNER:CASING:ORUUB G`(geotliermal`oscl e'd-lobfilViSs`^"""^v.;,• „,^S.
2.Well Construction Permit#: 4 " b COl IV FROM TO - _ D1AP 1 x I • riots MATERIAL M
List all applicable well construction permits e.WC,County,State,Variance,etc.) 4. I ft 4 (f ft CR,(r 9'l limn- f1- n' •
b�G •
3.Well'.Use(checkwelluse): ft (. it ✓ /;' in C� 6! I
Water Supply Well: ZI2FSQ2EIl:C_.'�"r"`�" ' c?
FROM TO • D �_ ; SLOT Tin MAT •,j
❑Agricultural l7Municipal/Public �• `q
❑Geothermal( eaten Coolin Supply) Residential Water Supply(sP9) ft in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) -18',' 'OUT'- -- -- ---- — e �.`'-"� �•
❑Irrigation .❑Wells>100,000 GPD '' •FROM; TO '^ 'MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply WeIl: • • :6 ft. 9 1 fG 1' (16.Ipf b"GY,, l,pi ! S
❑11'Onitering.-i::'z'`":}= .❑Recovery; • ' ft ft
In,A,.---,.,..--.-
ection Well: + •' `A i , ft. ft
I,
❑Aqu fer Recharge i DGroundwatei Remediation •
sr i•:; . 119 SAND/GRAVED_PACIC"(if-app`li`cable):-"-'t ..._:•____._.-__ :_. I'.
OAquifer Storage,andReecovery ;❑Salinity Barrier. 'FROM • TO •MATERTAL.1 eEMPLACEMENTMETEOD; •
•DAguiferTest E c _i:'-;❑StoIInwaterDlainage ft ft it ._ .. �' 1.-.::,' : ,.,
` ❑Expeitaental Technology j,, rt ).;(DSubsidence Control ft. It ' 1 MAR 1 -6• .
.t ❑Geothermal(Closed Loop) }, ' ❑Tracer 20,DIUI IGLOG(attachindditioicifiahee`ta ifiaec`essaiy)T T.--- '•''
DGeothemnal(Heating/Coohng Return),'`;❑Other(explain under421 R, rks) PROW TO :DESCRIPTION(color,1L�#d11na,'GofU,"'' pe,&iati,size,etc.)
Date Well Started•_ *.r...�r'1' S1. A .0 ft. Let rt ,�0e1� :~r'::,i's'k*i .�,• °--Y;iJ3i`
4 Date Well(s)Completed 3-r Wel. I. _ _ aQ ft J 6�rt •�� ,.I ,'• ,,,,!''
Phone#: rt rt G .:
Sa.6, Location p. `. %D 4/ 41y1�- 2'S cr, 5 f .. .Sow.1 11 It . ,r.VO C ,
:-�J�a 4��i :�D i1�e�r.U' �'C° a�i 15 it,. . t Lr�i ha •` �'P�t��-'`Yf766•
';I ,' `)i Facility/OwnerName '• FacilitylD#.(ifapplicable) f,' ! }' ;, i. f > r tom. ,
!r
'' I QOt ,OM �SN.I��Jry £9 Yl4 w lurk i '.w ft ft- , C -c am. ,y,,,�,-, L
L: •.physieaal,Addregss,City and:T�sP. . . .� • rift 1
County^ tf i• N � M •�P'P -,� ` /_ -Parcelldrn, ratioallo, - . • i� __ . `� ;,1
Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees:' ''s '
(ifwell fneld,one lat/long is'sufficient) _ 1,-, _. 22 Certification: l
r '
6CZ"
.Is(are)the well(s): ermanent ,or ❑Temporary .+I. Signature of Certified Well Con for`- i.°I Date • -, 1 ,:'i
' y
By signuig this form,Thereby certify that the we11(s)was(were)constructed in accordance with 1 .,
t['^ 15A NCAC 02C.0100 or 15A NCAC 02C'0200 Well Construction'Standards and that a ca i
;!:,; 7.Is this a repair to an existing weIl:. •LIY'es or ?(No '" i , Py
/ If this is a repair,fill out known well construction information and explain the nature of the• :o Arius record has beenprovided to the weU owner
s, • repair under#2lremarkrsectionoronthebackofthisform �•
r :: :,23.Site diagram or additional well details: ..`
' s' You ma use the back of this Page to ;o'vide,additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Y P g P
.` ',. add See Over'in Remarks Box You'ma also attach additional
,.. donstruction,only GW 1 is needed.'Indicate TOTAL NUMBER of wells., ▪ ( )• Y pages if necessary. r ;
•: drilled; •
24.SUBMITTAL INSTRIICTIONS
^•,},.;1, 9.TotalWeIl depth below land surface: 7001.... (ft) "Submit this GW-1 within 30 days of well completion per thefolIowingc?:;fir' For multiple wells list all depths ifdifferent(example;-300'and 2®100� ; '33
1024a. For All Wells: Original form to Division of Water Resources.(DWR),
f Static water level below top of casing: d ( ) -_;
I water level is above casing,use '+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617; ra
f fit i
11.Borehole diameter: 6 (tn,)Btt Off: 6 s 03 S " 24b.For Injection" Wells!Copyto D,WR,Underground Injection Control(IUC)
• Program,1636 MSC,Raleigh,NC 27699-1636
I
12.Well construction method: C•,1 r rp'}Ai y 2.4e:For Water Supply and Open-Loop Geothermal Return Wells Copy to the
(i.e.auger,rotary,cable,direct putt,etc.) county environmental health department'of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over Il100,000 GPD:Copyito DWP.;CCPCUA %
x t Permit Program,1611 MSC,Raleigh,NC 27699-1611 '
.3a.Yield(gpm) ,/5. '. •Method of test: rf� •1aa/ ' tt`
70% hth ' Oz Date Site Visited: �'-Iq-I Z.
13b.Disinfection type: 'Amount: Site Visited By: /I 6 I
Form GW-1 _ I_.,.Norttt Carolina Department of Environmental }
onmental Quality-Division of Water Resources ! ' Revised 6-b-2018 l'';
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