GW1--03235_Well Construction - GW1_20240528

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
_
( �v(' r14.WATER ZONES ;.4tr.
Rev(' FROM TO DESCRIPTION
Well Contractor Name ft. ft
���0� � ft. ( ft
NC Well Contractor Certification Number
'15.0 CASING(for multi=c sed wellsIOR LINER.(if'ip licable) •.
Yadkin Well Company, Inc. FROM To DINER Tffi l /eruAl. e-
ft, ft. in.
Company Name
0 � _ / '16:INNER C G OR TUBING,(geolhermal closed-loop)
2.Well Construction Permit#: W FROM TO DIAMETER_ THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) /ft. 6 i ft. 2.s 6. 0 in 6. u/N 6.1.V, Q1 ri ji
fW ✓ ,
3.Well Use(check well use): ft. ft in.
Water Supply Well: i7 S REM.
FROM TO DIAME SLOT SIZE THI)_KIYESS MATERIAL
❑Agricultural ❑MunicipalPublic /ft.
ft /. J (/J /❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in• (/❑Industrial/Commercial ❑Residential Water Supply(shared) : 18.GROUT
❑Irrigation ❑ flls>100,000 GPD FROM TO MA EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: mg �� 5 [Or l 0 ft. ft 01 ('/+ r_'�r
❑Monitoring ❑Recovery, ft. o J E/ ( ]
Injection Well: /- /
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
i 19 SAND/GRAVEL PACK(if applicabll_ •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
7
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRIT,LINGLOG(attach additional sheetaifnecessary)
FROM TO DESCRIPTLONcolor,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) q�ft. ft rt;:_r_
Date Well Started C(_2]_2 ))��jj ,� V4.Date Wells)Completed:�-1' '' Well ID#��{C 7�V ft. ft p_ t t
5 _ 1 t
Sa Well Location: Phone#: 2.' ie'7 .3-i(1 71.5 J ft. e, ft rat(L
Sr e- kill) fi(3,r ® &5't ft Cod
ft.
1 1,411
a- rpc 1.� �►�.r�
Facility/Owner Name Facility ID#(if applicable) ?Yf ft 1 KY1 ft rOLa 1�./0f
.1 y03 p1/i ?f' ' A ft7 pc,r I r,. l J Ytlift' l 5 i ft. cl rrt,.. 'ok I,.rz/5#i - rock
ftPhysical Address,City,and Zip
21.REMARKS Ids
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one las/long is sufficient) 22.Certification:
3 6 i 'i' -, ;'2 i N g 1 4:0 6i w �
JGrn. Y l " S•
-1-Z`l
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified ell 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 J to 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 afid explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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- is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: pp 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !SFJ (ft.)
For multiple wells list all depths ifdii different(example-3Q200'and 2(4)/00� Submit this GW-1 within 30 days of well completion per the following:
5 24a. For All Wells: Original form. to Division of Water Resources (DWR), ro
10.Static water level below top of casing:_ 6 3 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ..11`
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt Off: r �6` Program,1636 MSC,Raleigh,NC 27699-1636 ,
12.Well construction method: J&' I
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) Method of test: �� S
70% hth Date Site Visited: 4 -1,[ -X-)
13b.Disinfection type: Amount: �,.s' OZ Site Visited By: //de
Form GW-1 Noah rnr..c.,,pepartment of Environmental Quality-Division of Water Resources Revised 6-6-2018