GW1--05520_Well Construction - GW1_20240912

.n,1 CONSTRUCTION RECORD (GW-4' For Internal Use Only: ;
• • \
'•1.Web Contractor Information: '
Cc/k (- „, 14.WATERZONESPROM TO DESCRIPTIOIIWell Cncractor�J,.ame
1[19/ft. ft. / �i74 9 •/G$ 9 4
))
W A o,S9_CI ft• '1_,s ft. ...50- t 1 .�7 PG--1- & G P/1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER _THICKNESS MATERIAL
ft. ft. in. 1
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#:W X.(.. . ..i,\S 2-3 FROM TO DIAMETER THICIGIESS MATERIAL( j
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) "lQ ft. -All ft. j 54 in. ./9'' PAC' ille
ft ft. in.
3.Well Use(check well use):
17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Oeethermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft. in.
❑industrial/Commercial . , ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, LO ft. jkc'c/ f) -1® 1'fch 5
❑Mo:utoring ❑Recovery ft. ft. a• �1 `
Injection Well: FT -1, i 1�-�f .--
❑Aquifer Recharge ❑GroundwaterRemediation ft. ft. ' ��'� ' „
19.SAND/GRAVEL PACK(if applicable) `77.
❑Aou`.ferStoF3geandRecovery ❑Salinity Barrier FROM TO MATERIAL SEP it r41 ,(VIENTMETHOD
❑Aquifer Test . ❑Stormwater Drainage ft. ft. ' . 4
❑Exerimentdl Technology ❑Subsidence Control ft. ft. )t"''6R4 f'
^^
rs " ` fibux•i•-2,.. '
re-thermal(Closed Loop)1BJJCf/
OTracer 20.DRILLING LOG(attach additional sheets if aecessai3t)4'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/CodlingRetu n) DOther(explain under#21 Remarks) 0 ft. ft Re eitt�
r
4.Date Well(s)Completed: ' -111'.'2 Well /�A Q -.®G 7 ft. ft. .5®)) '1- zea.`c, C'Qv►'A�1
t.
5a.WellLocation: Phone # 76 4- y-57- /6/f Z g, 7-5 f Ali el jCA/! l/ t C
r W a p b 4--4- Tev6e��,. sue.,/ ✓a� I 616CCT yam/
Facility/Owner Name Facility DE*(if applicable) J.�� ft. �� ft hatd I; ��f/ �n.�1�, ��J ^
( L ) �a 1) /xjt Rhiev !a'Q C ,kavt0�J4 ft. ft. �7 J �(�Pf�-
�%� rH-1si s1 Address,City,and Zip ft. ft.
J4,04( ler. but,b 21.REMARKS
County Parcel Identification No.(PIN) BORES (2) DEPTH ( O)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( ) DIA OF LOOPS(��'
(ifweJ field,one lat/long is sufficient) 22.Certification: SDR OF LOOPS (.9' )
' '((•� b ` N $O . �q 9(9 vb W �/�- ._ . , 127 .2.��
6:Is(are)'the well(s): ❑Permanent or Ifii emporary Signature of Cc ed c Contractor Date .
By signing this form,I hereby certifil that the well(s)was(were)constructed in accordance with
7.Is this a repair to'an existing well: ❑Yes or ado ISA NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that o copy
If th.i is a repair,fill out known well construction information and explain the nature of the of this record has beenprovided to the well owner.
repair.under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:•
S.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.li GW-1 is_reeed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box);You may also attach additional pages if necessary.
dril;ed; / t- ,j- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 (ft.)
For multiple wells list all depths if difjerenl(example-3 00'and 2(0100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Originaliform to Division of Water Resources (DWR),
10.5tatic water level below top of casing: (ft.) Information Processing Unit,16.17 MSC,Raleigh,NC 2769 9-1 6 17
If water level is above casing,use'4"
1.Borehole diameter: 6 (in.) Bit Off: -1
1. 24b.For Injection Wells: Copy to DWR,Underground Infection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
• AIR ROTARY
12.Well construction Method: 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
�/') fi Permit Program,1611 MSC,Raleigh,NC 27699-1611 . ..
13a.Yield(gpm) /29✓ Method of test: f/ If
13E.Disinfection type: 70%HTH Amount:` '( -4- OZ DATE SITE VISITED: •�1 gS--2 •
Pr= ref •
VISITED BY: 0 v g>
Fo:-,GW-1 - North Carolina Department of Environmental Quality-Division of Water Reso ices Revised 6-6-2018