GW1--05464_Well Construction - GW1_20240912

JELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
+�1.Well ContractorInformation:
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aec� �::�� Tom: • -• •.�..��:�y.. ���z,' --.�_ . � .
aewa zoNEs:s�a�.,:3 ,;x:.s,.;,.�.z:�,,., �;,�;,::_ >.ti�u•:�.�
Well Contractor Name y FROM TO • DESCRIPTION
4�d 14 ft. GO ft 3 Cfrtr i
ft 2'7® ft 3 01114
NC Well Contractor Certification Number Q
YISxOIITER"GA.SINGVciimiiltVeased veIIs):ORLINER:(iCE-.'licable) Y..•i = is c
Yadkin Well Company, Inc. _FROM _ TO , DIAMETER THICKNESS MATERIAL
ft. ft , in.
CompanyName el .�
q :167IILVEIZ CASING:OIY:T[IB1NG:(geothermal closed:loop) ir;^�" i S
2.Well Construction Permit#: C` _FROM TO DIAMETER _ THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, ariance,etc) ..¢„ d ft D ft / 'At: SD R O e
3.Well Use(check well use): . a ft. 5� ft. G sle in. . ley 1 6 a k/
Water Supply Well: A.7 SCRFi.Etfi`"S:u'-.�.:17: i2 ,. -:"'`. . ;_ = "
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public _ ft ft in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft ft M.
❑ladustrial/Commercial OResidential Water-Supply(shared) .11e?GROUPi , -''a...V
❑inigation ❑Wells>100,000GPD FROM TO MATERIAL EMPL.ACEMENTMETHOD&AMOUNT
µ
Non-Water Supply Well: 0 ft' 3 ft. Hole Pl
OMonitoring pRecov 3 ft e ft (2?u1C��G30
Injection Well: 7 —
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation •
t:519'SAND/GRAv rTA.cr (rf.applicable)r �.:'.-,._n__.__ •
-
❑Aquifet Storage and Recovery oSalinity Barrier•.':,• , ' FROM TO MATERIAL EMPLACEMENT METHODM '''i
❑Aquifer Test DStormwatecDrainage ft, ft •1,,
❑Experimental Technology 0 Subsidence Control "ft: ft
5u
❑Geothermal(Closed Loop) OTracer r 201DRI Li G- OG(attach additrairsheedif necessnrg)"`" . `.�__�:;..,_LJ ,
❑Geothermal(Heating/Cooling tam) ❑Othee(explainunder#21Remarks)
FROM TO DESCRn'TzoN(colorhardness'soluroektypegratasizeetc)
Date Well Started $I i!L .� a /J/� 0 ft. 'l 1e ft ®f°
4.Date Well(s)Completed: l ii� Well LO# f7 "6 2 LI te ft. S 8 it G ra„0?
;,,,';.L. 5a.Well Location: ' Phone##:''15a .3-AS.57 -I 5 e ft fob ft (3cO n. Rock.
; � PLir¢,01S i 60 ft. 3 ft Gruen
Faculty/O `�wiferName Facilitty) #0applicable) ft ft. 1 ` _t /_`„e )ice
�. e `' Ffi! � N./30A ft. ft _ .2
r
Physical Address,City,and Zip ft. ft SE N .1 2 L U 2 4
.As i � � -.__. . .l
r21�][2EMARKS'w� v �" .,r
1f.10: .-.4"r+.e r Wray V'tit?*
County Parcel ldentifieationNo.(PIN) - f.,: E3iitw
Sb.Latitude and longitude in degl eeslnrinntes/seconds or decimal.degrees: 1
(if well field,,one lat/long is sufficient) ` - 22.Certification: ,
3G.6
6.Is(are)the well(s):Permanent or ❑Temporary Signahrr of C ed Well Contractor Date
o �
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance with
7:Is this a repair to an existing well: ❑Yes or �To ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
'If this is a repair,fill out)mown well construction information mid explain the nature of the of this record has been provided to the well owner.
• repair under#21 remark 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
construction,only I 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: (ft-) ' ;'ti,='.
For multiple wells list all depths tfdj Brent(example-3Q200'and 2QI00)• Submit this GW 1 within 30 days of well completion per the following: ':
24a. For All Wells: Original form to Division of Water Resources (DWR), 00
10.Static water level below top of casing:• :DC, (ft.) ®' sA
If water level is above casing use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
to 24b.For Injection'Wells:Co to D Underground Control C ""`'
11.Borehole diameter: � (in.)Bit Off: 4•�b� Copy � LF Injection � ) 1:"'
Q + Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: at 1 rf9 •` 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,`
o Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) CP Method of test: rii a•(r I -
o h t Date Site Visited: �791 1i_
13b.Disinfection type: 70�o th Amount Oz Site Visited By:•
� -
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
Price: -gel.- CA 4 f.e ' .