GW1--01726_Well Construction - GW1_20240315

'S_ LL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 0
1.Well Contractor Informs ti
'on: 1 "I
e)d Y A
Well Contractor Name )))��— FROM TO •' .DESCRIPTION• l0
C �'C ► (Aft-(Aft- / ?3f` 7 6 Pro/ d/cam
J I�dJ ft. ft. !
NC Well Contractor Certification Number GI
_?15:oUTTZR-.CASING(formiilti=cased iieIIs)':ORI�INElt.0 $P`E e)t ='�^ar=
Yadkin Well Company, Inc. FROM To DIAMETER THICKNESS MATERIAL _f®
. ft ft. J in.
Company Name '2 e'a- S_ �Z G$� g16 INNKRCeTSIlYG:ORcT11BING:(i;edtliermalcliiinoo-pr;f,.- �-="Z a'
2.Well Construction Permit#: #U Lb,- !'9- 23 zci®0 FROM TO . DIAMETER' TH oxrrEss MATERIALA
List all applicable well construction permits(i.e.WC,County,State,Variance,eta) 1 ft 7/ it fr ' Pi in- s1 W-a, ;j/V`,
3.Well Use(check well use): ft it in. .
Water Supply 17sSCREt9)7%:-":'-~. _:_._ a��_ `=
FROM TO' , _D PP Y Well: IMETER' SLOT SIZE- THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. - ft. in:
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial OP sidential Water Supply(shared) ;la8 GROUT;--_.. _-- --- --` .: - -` -----`:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL tE�MPLACEMENi'METHOD&AAMOOjUNT✓
Non-Water Supply Well: 0 ft' '2J 1 ft' , eA,Y,5 �1 rqv y i az6S
❑Monitoring ❑Recovery _ ft. 9` ft.
Injection Well: ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation
i_:19:`SAND/GRA'VECIACK'(If iiiiil cable) _-'LL —... `r:::..:=._ _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' •
❑Aquifer Test ❑Stormwater Drainage ft• ft • ,s
❑Experimental Technology ❑Subsidence Control ft• ft ..a
-.i
OGeothermal(Closed Loop) ❑Tracer 20iDRII INGLOG(attachiddiilon`al'sbeetiif"n'eciliiy);_:;`--""-_ _:_. . '
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIt oN(color,hardness,soW ack type goose size,etc.)
Date Well Started • , ' '13�'01s \ C) P 1 ft c� p,�
• 4.Date Well(s)Completed: p�•^13 V\ Weil ID# k (R OO ft �� it ;P [� i G I� i�®. �
Phone#: -g3 c --•9��7 it. &Xt Orf 6i C{- ld�
"
5a.Well Location:
rQtv-Rf'�/1�s® '
Facility/OwnerName"::., • , Facility ID# ifsP applicable) f 't ft ' t' L;I „f'. _ „1 :
76 S' 9 Arty, c - 5�s.1/kic/� 4
ft. ft
•
,MAR, z ?024 .
Physical Address,City,andZip •` a10,, : I • . - -
G21:.RF.NYARTCS —4•-----l±s .-7?;'� Sc: k` �1-1 ---_,_-_..
County Parcel Ideatifioatioa No,(PlN)' •
Sb.Latitude and longitude in degrees/minutes/seconds_or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
. 157'-...rC Oe)2_4)„ N go,,,.'9'9 S. 70"' w ' 2 -)3-29 .
•
•
6.Is(are)the well(s): r r ermanent or ❑Temporary tore f C ' ed Well Contractor 7 ate
l*HrAZ:
� �
By signing this form,I hereby certify that the welt(s)was(were)c•ns cte accordance with •
7.Is this a repair to an existing well: ❑Yes Or 0 1Vo 1SA NCAC 02C.0100 or ISA NCAC'02C.020.0 Well Construction SYanderds'and that a copy
If this is a repair,f it out known well"construction information and explain the nature of the of this record has been provided to the well owner. '
repair imder 421 remark section or on the back of this form. ''
23.Site diagram or additionalwell details:
8.For.Geo rob e/DPT or Closed Loo 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.
drilled:' 24.SUBMITTAL INSTRUCTIONS
9.Total well•depth below land surface: '(.a.1)--.. (ft) TO
For multiple wells list all depths if different(example-3(a)200'and 2®100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: '3 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ra
(in.)Blt Off: V C� 24b.For Injection-Wells:Copy to'DWR,Underground Injection Control(IUC) 4,
11.Borehole diameter:
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A-t" J2 r J 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
Cam.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
I� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / Method of test: IC) a �
° Date Site Visited: /-2 9
. 13b.Disinfection type: 70�0 hth Amount: I 0 0z Site Visited By: la rig
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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