GW1--02336_Well Construction - GW1_20240410

:', .10: LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ConiTa Pnformation: •
All,dl �� (S �./ d�/(i 14:,WATF,R'ZONES 11:::G:a,t�.1.-1-1.-1x .- s :1=27.;i'::::SL' :aa-.."?.124s:i ;•
Well Contractor Name FROM TO DESCRIPTION
3 VI?- 4 1.15.5.t't. y g6 ft
it. ft
NC Well Contractor CertificationNumber 15::OUTER.CA} SING'(fdi"mul@=cased weIis):OItT IPTER(i£`aplicable)i 77'''' ':.',T..• :
�.:^
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS I MATERIAL,� :,
ft. ft . in.
Company Name -
35.-- 5 A U 16:INlERRCASING.OR':TIIBING.(geothormal'elased=looThWi ..`' :i; ••• `.
2.Well Construction Permit#: FROM TO , DIAMETER THICKNESS MATERIAL
List all applicable well carslrirctionpermits(Le.UIC,County,State,Variance,etc.) 4 i ft. I Li ft (OSOin• o I pig Coyo vl'�..1
`
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMTO �V DIAMETER SLOT SIZE `THICKNESS MATERIAL
[Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 3g.esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial IDResidential Water Supply(shared) :118:GROUT- :""---- '".- -.— .- ----- --___
['Irrigation ❑Wells>100,000 GPD FROM ' TO , MA EMPLACEMENT l ETHOD&AMOINT
Non-Water Supply Well: b .ft.• ft. J*nt^`!t C 1 t'y pair/:!4
['Monitoring ❑Recovery ft. ft. I f `Go f
Injection Well: ft ft. ! v
❑Aquifer Recharge • ❑GroundwaterRemediation - - • _
i 19'SAND/GRAYF.LPACIC'Cif applicable) _.�-.�s _ ,
❑Aquifer Storage and Redovery ❑Salinity Barrier FROM -TO MATERIAL EMPIACEMENTMETHOD -
❑AquiferTest '❑StormwatecDrainage ft ft
['Experimental Technology "• -❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) • ❑Tracer : r.20 iDRI1)TLIGI:OG'(attacti additional"sheetaifnecwnry)=="=�",
❑Geothermal(Heating/ oline Rd- ; ❑Other(explain under#21 Remarks) FROM TO DE CRIPTION(color,hardness soNrock type gain She,etc)
Date Well Started, ' - ® ft - ft 0 e I
4.Date WelI(s)'Completed: `1 Zff Well Il7#. ` Oar Li, ft. 95 ft s d n J/ . ,I I •
5a Well Location: -.`•Phone#: 3-,; 7(�- .;(93'4 }75' ft. W— ft re t' ',i 4-1- 1
&lt9���A t l ft 13'7 ft t fOT l' tgr O,0 7,%}(-
Facility/Ows&Name Facility ID#(if applicable) 137 ft. S a ft at �• yc y y �'i•.
. `
® ft ft.
• Physical Address,City;and Zip •_ . ' - • ft ft. -
Count ! Parcel ldentificatiouNo.(PIN) -...�•ti .t L i--�-,L t`'i✓i t-&. .-i •
-1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: APR 1 E 2024 ,
(if well
well field,-one lat/longais,sufficient) 1 yry 22.Certification:
3�9 Q '1 I3 MI6 N Si t 3 I t t 1 W ',''y'/v�/�g71"'i'..\'E'til S'„•,:'ti�J/K,e^,Y:'F1 ) ,.'� _�1
6._Is(are)-the well(s): ernianent or OTemporary Signature of Certified Well Contractor Date
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance with _
'7.Is this a repair to an existing Well: ❑Yes or $PTo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cap;ic••=-
If this is a repair,fill dut known well construction information d 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 this form. �' •• ''
. 23.Site diagram or additional well details:
8:Far Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info $.., '
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. ,
dulled: ( ` 24.SUBMITTAL INSTRUCTIONS (t1
9.Total well depth below land surface: J O. (ft.) Submit this GW-1 within 30 days of well completion per the following: 3
For multiple wells Iist all depths if different(example-3Q200'and 2()a 100) 9.
10.Static water level below top of casing: So' (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)$If Off: 6,0—T 24b.For Injection"Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: (A t f /`c3 ilQty 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the C Z)
(ie.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 6 d'
r a e Permit Program,1611 MSC,Raleigh,NC 27 699-1 6 1 1
13a.Yield(gpm) J Method of test: Al air ;'�/
o '� . • Date Site Visited: J"
. 13b.Disinfection type: 70/o hfh Amount: QO. . OZ Site Visited By: I� To
Form G -16 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: JAL c,,,i taaa1- - •