GW1--03236_Well Construction - GW1_20240528

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well Contractor Name
S /Clht. /,.3•h. f '/.z Llis:�0 gc.ck.
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NC Well Contractor Certification Number 15.OUTER CASING(frir riiulti=eased w ORLINER(if iprlicable):
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
` / ' 16:INNER CASING OR TUBING'(geiithirMil closed-lobp)
2.Well Construction Permit#: f 0 5- ' 1 . FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ? ft. 6. ),,j`in. so
t,1{�,•�! PIT` 7...... .R •
3.Well Use(check well use): ft ft in.
a
Water Supply I Well: FROM
SCREEI!7.
F TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural [Municipal/Public ft. ft. in. ...`
['Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. ,
❑Industrial/Commercial ❑Residential Water Supply(shared) : 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6ft. )94 ft. y"i-eii1 ,..„,,,,„-el
❑Monitoring ['Recovery i cf ft. >7' ft. Om•51dir("1 Q 0 t'il
liosee
Injection Well: s ft. ft.
)
❑Aquifer Recharge .❑Groundwater Remediation
-
❑A['Aquifer Storage and Recovery ❑Salmi Barrier t.19.SAND/GRAVEL PACK(if applicable)
q $ tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
['Experimental Technology ['Subsidence Control ft. ft
L]Ueothermal(Closed Loop) ❑Tracer "20.DRE LING LOG(atfaeh`idditibualabeetiif:&6.i.iar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock typq n size,eta)
Date Well Started 44 ft. ' ft 1.
tkreotti v
4.Date Well(s)Completed: 5'i CP 3u�' Well m#,4t -, Jam+°S 1'7 ft 2 co ft fk. ; i.t, ,irek:
Sa.Well Location: Phone#: Ili)i! - '7t{A - 1 q 3 oft. 3 ''ft 3 riled"f ol i' P
ft. ft.
ft. ft
Facility/Owner Name Facility 1D#(if applicable)
44- L-n ht. ? � MC ft. ft.
3 S t c r l .r, M! f
Physical Address,City,and Zip rip/_`C ft. ft e024
w; 11(CS G7I®@OWN '.21.REMARKS ,
County Parcel Identification No,(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C
(if well field,one lat/long is sufficient) 22.Certification:
36 c ), ' 60 r' N gel ' ,?.Y 1 S ►rw l��aQf g� s D4).f 6`
6.Is(are)the well(s): �ermanent or ['Temporary SiQfC ed Well Contractor '"�` Date
Oka
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with Oa
7.Is this a repair to an existing well: ❑Yes or ll° 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction 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 owner.
repair under#21 remarla 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-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: . r.
•�' (ft.)
For multiple wells list all depths if different(example-3©200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
�y '? In24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: i S (ft.) formation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 _`
If water level is above casing,use"+" ?
( )Bit Off: ��� 31. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6m. Program, psi-
1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I'll V I`C ter)" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy la 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
13a.Yield(gpm) tic Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test:
70% hth oZ Date Site Visited: I A - 15- ,23
13b.Disinfection type: Amount: ter Site Visited By: AV,
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: