GW1--04342_Well Construction - GW1_20240722

:MML CONSTRUCTION RECORD (GW-1) For Internal Use Only: (�
1.Well Contractor Info tion:
S—o ( .�, ! I, 11r . 4t WATEgZONES
WeIlConhaetorName FROM TO DESCRIPTION
ft. 9U�'() it I ^�
NC Well Contractor Certification Number ;:POUTER L�il4I1VG fiirmult)sled"well ORT ILTFIt;i>a li'cstile`-:...'.
Yadkin Well Company, Inc. FROM TO DIAMETER 1�claarss MA1ZRLeL
CompenyName /� vGASING'OR;T[]BING `o'thermalr]BiedlSo
2.Well Construction Permit#: J ` FROM I TO I DIAMETER I THIC NMS MATERIAL
List all applicable well construction permits(.e.WIG Cowity,State,FarlancA etc) ft ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: .:S- •. - -._, .,, .. .;:... .. .. .,,. .. - _. .
FROM TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL,
❑Agricultural ❑Municipal/Public ft R In
❑Geothermal(Heating/Cooling Supply) P&dential Water Supply(single) ft ft in
❑Industrial/Commetnial ❑Residential Water Supply(shared) '18o G7t�UT
❑Ini ation ❑Wells>100,000 GPD FROM I TO MATERIAL. EWLACEMENT METHOD&AMOUNT
Non-Water Supply Wen: ft. 2® fcfe W(/i/' - �r!
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft ft
�"
❑Aquifer Recharge ❑GroundwaterRemediation ` �.' ,
`19.SAND/GRaIVII3�AGI :RTMP cable
❑Aquifer Storage and Recovery ❑SaliaityBarrier FROM TO MATMAL METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology DSubsidence Control ft. it Intl..,AAA ,i 9 -•I JRr.
❑Geothermal(Closed Loop) ❑Tracer '20:DR=, G1' iittieti iaditinn'aI"s
NMI— 2
❑Geothermal(I3eating/C Retum ❑Other(explain under#21 Remarks taoM TO DFS ON'colar hardnw,sollhoek sire eta
Date Well Started d ft 1
4.Date Well(s)Completed: -.t'I'Z�Well ID# �` it�C f ft ft /�/C�►t,"�
5 Well fsi
on V) P one#: Z 74tQ,3j`q 7 ft Ll 4 U ft �. " ,k �[
-M� s, ASiG7 C�
�Z( �- � f1 I ft. V` ft. rfV`f r
Facility/Owner Name Facility M#(if applicable) 6 ft /V V ft y-
' ft
�dle ��� �r iri�►f .��.�le�,.,,NC d ft a4 o
Physical Address,City,and Zip ft ft
4vStiI
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 47
(ifwell field,one lat/long is sufficient) hCeation:
W6.Is(are)the well(s): WPermanent or ❑Temporary dwell Contractor Date
� ,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Imo`V 15A 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 carder#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
constmction,only I�rW-1 is needed Indicate TOTAL NUMBER of wells ( 'See Over in Remarks Box)-You may also attach additional pages if necessary.
drilled: ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ® (ft.) Submit this GW-1 within 30 days of well completion per the followingi
For multiple wells list all depths ifdifferent(example-3©200'and 2©100)
VLF 56 24s. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,lb 17 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Bit Off:: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ( (r a'�' t� 24c.For Water$upply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county eavironmental 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) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
' �(�
70% hth oz Date Site Visited: — —2� r�wlk`
13b.Disinfection type: Amount: Site Visited By:
Form GW-1 North Carolina Department of Envirorun tam
Quality-Division of Water Resources Revised 6 6-2018