GW1--04300_Well Construction - GW1_20240722

•
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: _`
J' cri �q1c I As .14.WATER ZONES • =
FROM TO DESCRIPTION
Well Contractor Name 07 V
a Li sD A ft. ft �P�4) u f pti.vn3 4 S- "S
ft. ft •.J
NC Well Contractor Certification cation Number •
IS.OUTER CASING(nil-Multi-eised vvels�OR LINER(if applicable)
Yadkin Well Company, Inc. FROM TO DLAMETER L THICKNESS MATERIAL
1 ASIN1'UHING. eotl n /
Company Name ,, ., •
3 e\ 7 J 70 (ge o iertrial closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State, Variance,etc) , - f ft. 5Q ft. /(//q in. tO "R PVC -
in.
•7
3.Well Use(check well use): 1 ft. V ft.
„ SCREFls1.
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultlual ❑Municipal/Public f ft. in.
m❑Geotheral(Heating/Cooling Supply) residential Water Supply(single) ft ../ m. -/ ,/
❑Industrial/Cormnercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G ft oho ft. polr PS P6.rred Id_( 190.3.3
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage
ft.
❑Experimental Technology ❑Subsidence Control A
...**"..‘"--
ElGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if.necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain cure ern)
Date Well Started 6'13 7 si ^�/� 0 ft. ys ft. ss Li
4.Date Well(s)Completed: '7J,y Well ID#A J(C /eq3E It- ft. J 063 ft- Groh_
5a.Well Location: Phone#:33L- q t 2-41 Xi, ft. ft
riGA -a Aside,' 4 try ft ft. f � c
Facility/Owner Name Facility ID#(if applic ble) ft. ft.
0,;,r�ett Dr
Aze.tvt;6J!',2gt26 ft. ft. JULT ` 2•202=i 6"
Physical Address�ity,and Zip ft. ft
21.REMARKS . ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - (B
(if well field,one lat/long is sufficient) 22.Certification:
3 GC 17 ' 31 , N gl' 31 you W i, I av
6.Is(are)the well(s): Permanent or ❑Temporary
Signaturd of Ce ed Well Contra Date 6'
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 orIo ISA 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 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 GeoprobelDPT 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-/s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yo i may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 0o 3 (ft.)
For multiple wells list all depths if different(example-3Q200'and 2©I001 Submit this GW-1 within 30 days of well completion per the following:
,co (ft.) 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 Q"
If water level is above casing,use"+"
/- 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 0,
11.Borehole diameter: l27 (in.)Bit Off: S.958 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Al rO ay y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the f h
(i.e.auger,rotary,cable,direct push,etc.) I 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
1/ a Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Z •
Method of test: at 1
70% hth Date Site Visited: er/8/2 3
13b.Disinfection type: Amount: y3 OZ Site Visited By: M A
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources r Revised 6-6-2018
Price: Su Co" -1-f a e_ 4-