GW1--05461_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
"-r"-..t,.-1 Well Contractor Information:
ecr1 1"-)CL ICe AS 17141MATTEVZONES''2.'__...4:y.•t aS:9.�. '1.0=; '.au:�..:.�;':.::'3-c ,,.1 .
We1lContractOrName FROM TO • DESCRIPTION
11
• ft. 3.10 ft 3 GPI
,LI S a A ft. 610 ft. I G fig+ '�
NC Well Contractor Certification Number • 15:01.11ER:CASING'(formiilfi eseCieIIs)'ORL1NERt(if$p liaili ;t:a--:::f_=:7:
Yadkin Well Company, Inc. FROM TO DIAMETER TH CHN SS 1 MATERIAL
ft, ft in.
Company Name �y iI6:INPIER:CASING.ORt.TQBRNG eotliermal'dosed=Ioo -' _ =>s._,_."
2.Well Construction Permit it: litf(a FROM TO DIAMETER • THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4 /ft. 41 I ft G S/D in.
n I . 188 GaC v
3.Well Use(check well use): ft. ft �+ 0 in.
Water Supply Well: ' J7`SCRFM—t:'.=emu' '_`_=_77._: .-_ 7_ __" ti
FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) "Residential Water Supply(single) ft ft in. Jk
❑lndustrial/Commercial /r❑_Residential Water Supply(shared) 18G1tQUTC " " "` '.
• ❑Irigation - DWells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMODNT
Non-Water Supply Weliv ' - • 0 ft 9 q ft. Half Pl u ct Oo j eci 15 1 Q S,S
❑Monitoring ❑Recovery ft. ft •
•7
• Injection Well: •
ft. ft. •
❑Aquifer Recharge •OGroundwaterRemediation _
❑Aquifer Storage and Recovery OSalinity$alTier I.19..SAND/GRAVEI PACK(ifapplicable)=.12 _i" .. .___-_� � .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test • ❑StormwaterDrainage ft_ ft •
`•` OExperiimental Technology OSubsidence Control ft ft
.DGthermal(Closed Loop) ❑Tracer 1:201,DRR IINGI:OG•(attarchadditionslsLeetfifXlecessary)i'Y^ ___ _. _ _.
1•i:t'e.':: FROM TO DESCRIPTION(color,hardness,sail/reek type,grain size,etc.)
• OGeetlierm q�al(Heating/Co 4.etrrnp) ❑Other(explain under#21 Remarks)
'' ':Date;V,l(ell Started `7Ilb 14 6f` �47I ft' S0 y/
-4:DafeWell(s)Completed: 1 (ail Spa Well ID# 0 a y 1-, .10 ft ry A l*P
,;: ' . Phone# v� o 1�r a� fr. ft
,$0112bcation: 3Cm' d 3 /'
1�1,'` ise.rety' _xt ft. ft.
-Facility/.Name Facility I.D#(if applicable) it5 '„n ft. ft Y c=-. ='►o 'r .
•P1fysical Address,City,and Zip �� ft. ft S E P C 1 U 14
L` ' VII `,`'31RF.
_ MARICSn: vim' -1.--:=4 - ,77, r ._
_ ...._, __ ��
0.5rNV'"12 Unit
,Couuty, ,;,. ?,.•,. Parcel Identification No.(PIN)
:y ` 5b.Tatitude'and Iongitude in degrees/minutes/seconds or decimal degrees: •
' ' y' (if well field;:one lit/long is sufficient) 22.Certification:
.3' =1•"C e 31,e,ei N kV. 3, , 75 W 7/ M'I 2�
•'I. .6.Is(are)the well(s):�ermanent or OTemporary Signatui eta •ed We Con�l tractor Dotter
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
1'
".•'•', .'7.Is�this a repair to an existing well: ❑Yes or l'lo 15A NCAC 02C.0100 or I5A NCAC 01C.0200 Well Construction Standards and that a copyof this record has been provided to the well owner.
-.•t IJthis:is a repair,fill out known well construction information and explain the nature of the
;!,_,;•
.;::..•_rcpdir'itnder#21 remarkssection or on the backofthisfo»n
• ;::. • 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 GW-1 is needed. Indicate TOTAL NUMBER of wells
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I. 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: I—7®.3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(g200'and 2Q00)1 ...
24a. For All Wells: Original form to Divisiob i Water Resources (DWR),
10.Static water level below top of casing: s® (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699,1617 '
If water level is above casing use"+"
11.Borehole diameter: (in.)Bit Off:
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)r
Program,1636 MSC,Raleigh,NC127699-1636
•12.Well construction method: p e v? t' �' 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
L Permit Program,1611 MSC,Raleigh,NC 27699-16117 o..'
13a.Yield(gpm) Method of test: gd.tf iisr ,/ ' (ly
70% hth Date Site Visited: a//"l'r72 y •
. 13b.Disinfection type: Amount: 1 OZ Site Visited By: v ,ram` .
Form GW-1_tr North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018