GW1--04390_Well Construction - GW1_20240723

Pr-
' :`-= o'ia LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
a*En-e-,5 146 I I 0.4.'NAM ZONES
FROM TO . ' DESCRIPTION
Well Contractor Name too ft. IZ[7 it s1�_ \�t /.r,�� 2
ft. ft-
ft
NC Well Contractor Certification Number :15:-0 CASENG(far`miilti"-:lied•ireIG):OR'LINFIZ(ifapplicalie) '
Yadkin Well Company, Inc. FROM T _D FIR ((NES S 1 mARt
ft. I /
Company Name o� 16% C G_OR'a UB G:((eotliei mal"'do9ed=1"o"op)
I �7 0 */ - y FROM TO DIAMETJt R THICKNESS /MATERIAL(
L.Well Construction well
c Permitconstruction
on p f v Count)", eta) ,,,�I ft. �3 ft 6/e�-in- 6t, s6 (jGl V ,!`}te 1
List all applicable xYl/cansiruction permits �.e.UIC,Coup State,Variance,
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THl S Fyrlt.
❑Agricultural ❑Municipal/Public ft ft. m
❑Geotheral(Heating/Cooling Supply) .i*.esidential Water Supply(single) ft ft. �•
m
❑Industrial/Commercial ❑Residential Water Supply(shared) :.'18 GRour (((
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .��
�J
Non-Water Supply Well: v ft. y f ft. Pa r-I 1(:.l_
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft tA
❑Aquifer Recharge ❑Groundwater Remediation
V19.5 '/G1tAV.L+IIP.ACIC( pplicable);' .. :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEFIAL EMPLACEMENT T METHOD
❑Aquifer Test IL ///
❑StormwaterDrainage ft ft. / /
❑Experimental Technology DSubsidence Control ft. ft / .. ,
❑Geothermal(Closed Loop) ❑Tracer 20:DR1LISNGI. G(attsih addltionil sIeeta if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) t=
❑Geothermal(Heating/ olmgaReture ❑Other(explain under#21Remarks) PY ft• I ft. f` r.
Date Well Started q+ 1- ll.• /,�/'� ,(L� v °fl
4.Date Well(s)Completed:?-i V Well ID#4 t v`-92l! / l 0 ft' (,lo) ft 1 %yv-
5a.Well Location: Phone#: (,.,if'7�'-.3 i i j0 Zft. t Z.L ft ` l(,Mn IrOCf. Y -
C/' r r CO I e, 'f Fj�
4 e 3 N Pert C.$o ekly ZL ft- loo3 ft, wi` t�
/ .FacilityID#(if applicable) ft ft -
Facility/OwnerNama J� PP J) 1 i ti.- ‘„ 4., ‘! 1_/
.-
Srare!1 1 () -Pr I)1Vw/11 C./C •
ft. ft
Physical Address,City,and Zip41: Gl '
VI,l iscaV•° `+r4. ,$ UP.. )County ') PareelIdentificationNo.(PIN) - ty , _��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) ,+ 22.Certification: -C
3( . 6
7 ItL N g1r J•, 4U W 7 -.2-Lt q
6.Is(are)the well(s):jiirt ermanent or ❑Temporary
Signature of Ce. ed Well Contra Sr Date
By sio ing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )(No 1S!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. U
repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this gage to provide additional well construction info
8.For Geonron only 1 GW-1 Closed-Loop Geothermal Wells having the samells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. ....4
construction, 1 is needed. Indicate TOTAL NUMBER of wells
drilled: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IOD3 (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: �� (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
['r�(� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: ( •)Bit Off: / Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: al, ✓i1 Tti 17 24c.For Water Supply and O en-Lao 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: f• (+)✓ `�'
Date Site Visited:
70% hth oz Site Visited B -
13b.Disinfection type: Amount: 2 Y ,
Revised 6-6-2015
Form GW_1 North Carolina Department of Environmental Quality-Division of Water Resources
Price: