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Home My WebLink AboutGW1--01688_Well Construction - GW1_20240315 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 ig .....• 1.Well Contractor Information: /' � Well Contractor 3. ,yNa mmee • FROM TO DESCRIPTION NC Well Contractor Certification Number �� ?, 15,ODTER':GASING(for`riiultrcasreeweRWORLINER(if ap livable)---r.I;"-.::,s'n S Yadkin Well Company, Inc. FROM TO DIAMETER II THICKNESS MATEIIAL ft. ft in. p CompanyName :i16.s M F.R CASING:OR:TDBING(geothermal`closed:loop)n,`t'_.'-""=ti 9",>_p 2.Well Construction Permit#: / c+ Sri FROM TO DIAMETER i THICKNESS MATERIAL _ List all applicable well construction permits(Ie.UIC,County,State,,Variance,etc) „f , ft.-i 3/ ft C(1S- in. Sl^l-) i P t"tr 3.Well Use(check well use): ft. 1( it 1i in. !J °i i":-.1VSCREEl�.` ;r ..'-': ;_"_,'..,�_______17 Water Supply Well: FROM TO DIAMETER SLOT SIZEy THICKNESS MATERIALv . . DAgricultural _ ❑Municipal)Ptiblic ft. ft. in. ❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) ft ft. in 1 0 DladustriaUCommercial I9Resideatial Water Supply(shared) „181GRODTU�.:::.v _`-'" _ ._ ii-�= - Dltrigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENTMETHo1)&AMOo�T Non-Water Supply Well: ft ft �j OMonitoringPP Y ❑Recov ft. �� ft. 4141. 1 c bt `oIs pa(Ace �' I o[J Injection Well: • ft. ft �g�s ❑Aquifer Recharge ❑Groundwater Remediation �_. -. __ i=•19:'SAD/GB:AVPI;PAt '(iflp-plicalile)`�" _ _�_ = y . . DAquifer Storage and Recovery ❑Salinity Bather FROM 'TO MATEBIAL:a-, .--•,•.EMPLAFCEMENTMETHOD + DAquifer DStormwaterDraina e' ft ft irk t, P$ .T. A .. ❑Experimental Technology DSubsidence Control •• ft it h n[J 1 r fl A ❑Geothermal(Closed Loop) • ❑Tracer 20:DRI1LIPTGLOG.(ittactiifdditimiiltieta'ifn`eceasai•Y)__'= ___;. ❑Geotlleimal "FROM TO DESCRIPTION(color,hardness,sail/rock t�grain size,etc) . (Heating/CoolingRetum . ❑Other(explainunder#21Remarks)' ,,._ FjTs: ' ' Date Well Started a-I - •- . /�/f ® 'ft /�` ft. �tl ri,o „t3 fir: L 4.Date Well(s)Completed: A.r/,6-1 -Well ID#44a a q 6, . ,*:: ft. 7 0 ft �� 5a.Well Location: -Phbrie#: /t51®q(sti=•Oil®. 70 ft 12S ft .tf'I-- I.19caw ''f\ l IrGG - t t y.d.r �Tii. :,: t I '1. p4�� ft. r3 s ft �}l�� ra y !f`A91 Facility/OwnerName Facility ID#(if applicable) '. 13 S ft. 14 ft Me'? re A t•7 2• J-/ , ` 11 ; . - __G�qr a?v- N e, 17 ft P 6-6 f�t-Ut�i ;'�jaCr . Ph_ysicalAddress;City,add Zip . ' .2467m l � ir."-LP�'Z ft M ir,V (L+f a--. s ,County Parcel Identification No.(PIN) ..q 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -' , fie • ' (if well field,one lat/louig is sufficient) 22:Certification: ' 3 6., 2'L it- .iO:� /'- a . `..,N . d. 7'8" G'o$- w E' C v4,'L �J` I c - . 6,Is(are)the wells) ermanerit or DTemporary Signature of Certified Well Contractor ' I Date • . ,i By signing this form,I hereby certify that the'well(s)was(were)constructed in accordance with 4 7.Is this a repair-to-an existing w:ll: DYes or to I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constriction 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 bwner. • repair under#21remarin'section or on.theback of this farm. ' 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 I.GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: - f� 24.SUBMIT.AL INSTRUCTIONS ro 9.Total well depth below lan4 surface: -1 Lia` (ft.) I For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of ell completion per the following: 24a. For All Wells: Original form toI Division of Water Resources (DWR), ro 10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 -0 If water level is above casing,use"+" . 11.Borehole diameter: - (in.)Bit Off: (1 W e/c 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) tili Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: Get.0ll fO 44,a vr 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the • (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,NC 27699-1611 13a.Yield(gpm) I ® Method of test: tit. A/i • t6! 70% hth Date Site Visited: Sin�i/,Z-3 13b.Disinfection type: Amount: 1.g Oz Site Visited By: �Ut�I I - V e d 1 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i ; Revised 6-6-2018 Price: .