GW1--03270_Well Construction - GW1_20240528

CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: E
C•l 7 I� r ;.:4:WATEIeZONES`...s�e
Well Contractor Name FROM , TO DESCRIPTION Q� "
)fw9.ft I To ft. •Pre r1�C at. 1-• (Ital..
r •.s
tc�ISY�T I W-'1- C! l .--
NC Well Contractor Certification Number ( ft (� fL 3� {h_,r 1`41
lfiTOIITF�':1SIlVG(foi ii ltireir ed'vi llLODR: /LINERi(ifnp licatilef::
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16`iINNERCASING:OR;fUBING;(geatliermal'clnsealoop)' .
2.Well Construction Permit#: 3- FROM TO i DIAMETER THICKNESS TERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 1 ft. 37 ft tA4 in- S\ ..3. (
3.Well Use(check well use): \ ft. ft (9 in. V Vim/
Water Supply Well: �17:SCREIq�;
FROM TO DIAMETER _SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M//unicipaUPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) Ik esidential Water Supply(single) fL ft in.
❑Industrial/Commercial DResidential Water Supply(shared)•
18'GRODT:::
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f. a4 ft. 8eh (f1i j�- (itok}/ 1J06
ft
❑Monitoring ❑Recovery , ft v
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation -,
j.`:19.SAND/Otis-FS Y.AC e ifspplicaliie) -
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
DAquifer Test ❑Stonnwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer ''20.DRtLLINGIOG(attach idditianarilaeets if necesiary):`:'_.•..:1 .: .. . _
❑Geothermal(Heating/Coolina Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,baroness,soillrcck type,grain size,etc.)
Date Well Started ^ I' V� ft 7 ft 56► 1
4.Date Well(s)Completed: ^ �t Well ID#14i I 9 ft- i C ft &c Fy t,,,c I�tS u 1
5a.Well Location: Phone#: 3C'( -%/6Q 1.�5 ft. se ft. y •J
CoI L I err go ft. ka ft. Aiypt 6k.L'. r�� l`TL 5
Is
Facility/Owner Name Facility ID#(if applicable) ft. ft'
S c .; L 14 be-1. 1,9k A; 4 i, NC ft. ft 6"
Physical Address,City,and ip '2.1E105 ft. ft ��
Da,,d 3c i.. i.21.ylEM-A`R S.. . - ,)..:.'."
County Parcel Identification No.(PIN) S 20;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(if well field,one lat/long is sufficient) .. .
22.Certification: � �.i 'ti
3,37 coin N so, it jeer W /� 1-1 ,�(1- `1
6.Is(are)the well(s): QPermanent or ❑Temporary
SignCertified Well Contractor Date
By signing this forte,'hereby certify tha.'the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *IC 15A NCAC 02C.0100 or 15A NCAC(EC.0200 Well Construction Standards and that a copy,C)
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 j 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: AC,d.r� (ft.) '\
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),ro
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10.Static water level below top of casing: 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 4116
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: /� (in.)B It Off: g Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /�-i flu
u ley 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) a 1 Method of test: MACctO 1 n 4 hz
o Date Site Visited: y�-2-Y poor"ki �� �
70/n hth '^
13b.Disinfection type: Amount: V OZ Site Visited By: Odn
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018