GW1--03575_Well Construction - GW1_20240613

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ELL c 1 RUCTION RECORD(GW-1) For Internal Use Only: 3
1.Well Contractor Information: t^
SeCr7 wai-kc, S iI4.WATER ZONES ' ....'::' PP
Well Contractor Name I FROM TO DESCRIPTION
ati S.-D. A ft. I. ft �V/ GPM
NC Well Contractor Certification Numb fe p • f L i Y2 GPI r)
er
15.OU1ER CASING(foi multi cased wells)OR LINER(if'i'llcable)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
^ �� .s W '16 INNER CASING OR'.TUBING(abthermal closed-loop)
2.Well Construction Permit#: 9 FROM TO DIAMETER THICKNESS MATERIAL
Litt all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 41 ft SO ft G At in- SPI2 a I et/C.
3.Well Use(check well use): ft. ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public ft ft in.
DGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft ft. in.
Dlndustrial/Commercial Q.esidential Water Supply(shared)
;.:18i GROUT
❑litigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 241 ft' tio(c _ Poo togi /I, 625s
❑Monitoring ❑Recovery ft. ft
Injection Well: -
ft. ft
DAquifer Recharge ❑Groundwater Remediatien
• 119.SAND/GRAVEL PACK'(if'iypliehble) •
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
DAquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer ''20:DRIETTNGLOG(attach'ad'dittonalsheenifnecessary)
❑Geothermal(Heating/Cooling çtu& ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardaeu soil/reek type grain sire etc)
Date Well Started Slip � 0 ft' yS ft. SOif
4.Date Well(s)Completed: S I 1313 Well IN s— V Lcy ft' .S? ft Gra/ti1
5a.Well Location: f/}) Phone#: 3 G'-�/3-09�5Q',fj.• -7 ft I �1 ft 8ro�n R OC
IC
"'A 1 " '4k1 /� the- Cal // GOO� G310da ft. PG ran Or r--.--,r--
Facility/Owner Name Facility ID#(if applicable) ft. ft. \L L•,L..;V E U
44/D3 r/f Crr eIc tatkr-Ay feryson ft' ft JUN 1 5, 1621
Physical Address,City,and Zip / �f ft ft.
l�//free Main -• 2 S Y !�y/3- 3 0.3..r •
21.REMARKS' tffiv:.r .1t3 truer
ai,;:� L.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rG"t
(if well field,one lat/long is sufficient) 22.Certification: /'
3 0 jl. 3-3f/N Sl -2.1'— Y?1G1 W ( S1171.33 04
6,Is(are)the wa(s): ¢V'ermanent or ❑Temporary signer tr!`ofCertlfied Well 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: DYes or Ago ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell out known well construction information and 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 G,W-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: 3o1 (ft) Submit this GW-1 within 30 days of well completion per the following: ro
For multiple wells list all depths ifdti different(example-3Q200'and 2Q100)
�O 24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wafer level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)`�
11.Borehole diameter: on.)Bit Off: .�Q q Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: role 4 h,, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the P,
(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) ^ ,' Permit Program,1611 MSC,Raleigh,NC 27699-1611
ie Method of test: V'
70% hth Date Site Visited: � / 1.3
13b.Disinfection type: Amount: ](4 OZ' Site Visited By:/ IJ
on,
Form GW-1„ ,, _ North Carolina Department of Environmental 1 L iO W T'lt �p Qua ity- ry stun of a er ces t Revised 6-6-2018
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