GW1--05530_Well Construction - GW1_20240913

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ! i
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'I R'ell Contractorflnformation: Cave
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FROM TO ' DESCRIPTION
Well Contractor Narne /
NC Well Contractor1 U Certification Number f® "i . i y�J�tr
R.OISINO(fo%mtilfi;ast:diwellq:01CU FAV ids"'liMiliThM:. . co
Yadkin Well Company, Inc. FROM TO nIAMETER •THICKNESS 1 MATERIAL .''S
ft, ft ' in. , G
Company Name _..l:,:.<-
a gf6n NER;GASING2ORR'i7BINarg ofiermal'do"`4.infili'�'!, :;;•. ,. Q.:
2.Well Construction Permit#: ll/' FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UUC,Comity,State,Variance,etc.) ,t--1 it' l ft. 6'( 1?,S' s pA;,t P V` -
3.Well Use(check well use): R. ft. in.
Water Supply Well: 7I:7:,N EI .::::3$: - >-:_ _'_ , :�::` ::: —: '"`-`.-_ . .:
FROM TO DIAMETER ySLOT't7.F THICKNESS MATERIAL
❑Agricultural ❑Municipal/Piiblic ft. ft J in-
0 Geothernial(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft, in.
❑IndustriaUCommercial residential Water Supply(shared) GROUTo-;:r'^: :f T i-18:, a.Li air w;43.. _ ._...
❑Irrigation ❑Wells>100,000 GPD FROM TO, MATERIAL ']] EMPLA M CEMENT ETH M OD&AOUNT
Non-Water Supply Well: • ® ft' 2 6 -ftB•vI' O 1 tt e-1,•t.) p o w ea
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft •
❑Aquifer Recharge Groundwater Remediation
r.19:.SANDliPaN3UMIMif;aPpli'c"a71e) nr.,. : 's:::-.." Y
❑Aquifer Storage and Recovery ❑Salinity Barrier . - FROM TO . , MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ' , ft. • -ft.
❑Experimental Technology ❑Subsidence Control ft. ft •
DGeothermal(Closed Loop) ❑Tracer `20 DR1fi N&LOG(attieti udditionil"slieeti'idriecessaiy):=f.',--'47 `.,Y. '
❑Geothermal(Heating/cooling Rettozn) ID Other(explain under#21 Remark) �a OMTO . DESCRmTIoi 1f(Color,hardness,soil/rack type grain size,ern)
' Date Well Started s-"j• t, e� 3 I `'
4,Date Wells Completed: ''17-2 4 Well ID#.t _s •` 0 g'
15a.WellLocation: • Phone#:3 -•J 9-7VRk iift Sd�-ft. Mid -sa', oct `- �en' e. 7t
Oaf eaI A - OaCelto.CpaCelie/ si-Geo � ) •
ft,. . tt
Facility/OwnerName �q ( . ( �Fa`ciillity ID#(if applicable) l ft ft. F _ t^�y-1.; f.�,
le Pa.
Physical Address,City,and Zip , .j 5 ft ft SE P 1 0 20?4
, ��tes' - . . _. - .- rYi _�„ �';ir d- T.;i:: • R
Cr
County Parcel Identification No.(PIN) ,,; y of t' v 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:'
(if well field,one let/long is sufficient) 22.Certification: p,„... �l
- g 4 SG d 7o, N K.)e 9,Y•SS& 1J! w r 7 d z.t
6.Is(are)the well(s): permanent or ❑Temporary Signature of Certified Well Contractor P�t.at t
Ily signing this form,I hereby certify at he wel was(were)constructed in ordance with
7.Is this a repair to an existing well: ❑•Yes or 30 15A NCAC 02C.0100 or ISA NCAC C.020 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 under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geo robelAPT or Closed-Loop Geothermal Wells Navin the same You may use the back of this page to provide additional well construction info
<<J - p p g (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• &instruction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
:.;; 'drilled: 2 I 24.SUBMITTAL INSTRUCTIONS
9.Total depth below laud surface: Q (ft.) Submit this GW 1 within 30 days of well completion per the following:
. ;For nrttltiple wells list all depth's if different(example-3Q200'and 2Q100')
24a.For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6
(ft) Infomtation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ti If water level is above casing,use"+"• •
1 i. C.g /� 24b,For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
11.$orehoIediameter: (in.)Bit Off: ` /�
�l Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: a C'-t RCii-ay.If 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 R)
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 YJ
13a.Yield(gpm) �- Method of test:_ 1.
70% Nth Date Site Visited: -/�-2 t � c o��
• . 13b.Disinfection type: Amount: 2 Oz Site Visited By: Am 1 ",
6-. 7 ! gQ a 4%.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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