GW1--03600_Well Construction - GW1_20240613

a R,ci,CONSTRUCTION RECORD (GW-1) For Internal Use Only:
� t a
1.Well Contractor
f Information:
1t5 T.714.WA'1ratZONES.:.
Well Contractor Name FROM TO DESCRIPTION
(ILO' (.0,..‘3ft• 4,f4 6.00y Sferi- J 6 P/41 441 -g:
11- C f. ft
NC Well Contractor ertification Number 15.OUTER CASING(tor multi.cased wells)OR LINER Olio licable)-.:, t.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft in.
Company Name /� �i p :16.INNER CASING OR.TCBING(geothermal closed:Ilion):
2.Well Construction Permit#: P/.w�•alb 25100S FROM _ TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) 1 I ft. i to ft. i n f/•1 in. 51)r�-a, lPV/
3.Well Use(check well use): _ ft �V V ft. in [ _
W Supply Well: FRO TO DIAMETER _SLOT SIZE THICKNESS MATERIAL,
cultural ❑Municipal/Public ft ft In.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) I8:GROUT
❑hrigati on ❑Wells>100,000 GPD FROM TO p,s .9 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft.
2 Lim
aI! osil 1 7 of S
❑Monitoring ❑Recovery ft. ift.
Injection Well: ft. ft.
❑Aquifer Recharge .❑Groundwater Remediatian
119.SAND/GRAVEL PACK-(if applicable)'
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soilirock type,grain size,etc)
Date Well Started 5-7-7.4 O ft' 15).ft SD➢ i '4
4.Date Wells)Completed:5-10``,Z� Well ID# As c?J g� ft l gS0 ft t _f',+ TC71 ik Q1/��s 1 l ,q�+
Sa.Well Location: Phone#: 33G" `7k$0&11 tj )omit ft. 56f+ )1�1' i5. y �'iX'�`/e, J
l�' ft. ft. _ l‘ %
Facility/Owner Name T d ly,s j,�J.,,�j k. Facility ID#(if applicable) ft. ft. V E LiS
&A-CcLA.te,hooL .4--(tCt r. ft. ft. it-'N 1 S 2024 It-
Physical Address,City,and Zip 1Q'A�� ft ft I r sty;S s i•r.Z ?-r r tidir J
[4 v ;k AR lY 2i:REMeRxs. ekyribir) bJ:
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
;3�.•3�773.)' N c7. 7i 7efk W _ - �.
`s-/0-DI
6.Is(are)the well(s): Eilsermanent or OTemporary Signature of e ell Contractor Date
�� By signing this form,I hereby tern,fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or Clio 1SA 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. v l
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: �'t�
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 C
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 f-_V�`
W
9.Total well depth below land surface: f es! (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2®100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Co5. O Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
7924b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: R i r raja-Y.)" 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) I Method of test: C:C4-41 a.1(triAl.
Date Site Visited:
y By:
70% hth Amount: oz Site Visited B 51r% C' ""�
13b.Disinfection type:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I