GW1--05551_Well Construction - GW1_20240913

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WELL CONSTRUCTION RECORD (GW-11 • For Internal Use Only: ,
1.Well Contractor Information:
g3e, kJ0101(.17 7L4',WATIae20NE5'_s-
FROM PTO .•• DESCRIPTION
Well Contractor���� • /6��+ft. /, •��t /I� Argil ' %
ft ft.
NC Well Contractor Certification Number Y 15."OUTEE;:eASING(hiniiulitritied�v O
Yadkin Well Company, Inc. ( RRIxSS��li imai _
FROM TO DIAMETER TffiCKPII+SS� MATERIAL
ft. ft in.
Company Name '
yp� 4% W q If.f 5S'INNER';CASItiGOR',TEB.111W geothermal cl6aid;l80 sr:-a_4h,....:-..
2.Well Constriction Permit#:_ CJ FROM TO • DIAMETER _THICKNESS MATERIAL
List all applicable well construction permits lie UIC,County,State,Variance,etc.) 1 ft 41/ ft Ii.3',� n ,,® u v
3.Well Use(check well use): • + ft ft in.
Water Simply Well: •
0..7:_S 7s,:`::•. _->'= _.�.,'�'.`•r� ; ;r_:::::Al;"',—,--3—__.,. _: .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Xletesidential Water Supply(single) ft ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) )-18's°CrZt6UT ` �•
Y ' .;" ^:" - .. '�a.:.:1;7 : .. . •• ..
❑Inigation ❑Wells>100,000GPD FROM TO MATERIAL ' EMPIACEMENTMETHOD&AMOUNT
Non-Water Supply Well: .. S' ft,® ft ��/.- !f C .gip
[Monitoring ORecovery .- ft �'a
r ell,
Injection Well: t�� doseS'���� ZA6�
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation • -_
❑Aquifer StorageRecovery • �, j 19:5AND(GI2AS AQ {ifsr'p cati]ej'>'...;.`. ,;,<.:�41, -'a`,i� =:.-,;• °,
and ❑Salim Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed ❑'IYacer ';2O: lL INGIOG atf lillditi"oriiIsbeet5if:iiecrs's"" `Mr�'•=:',r,,^. :•+
Loop) ( may)'= •_
❑Geothermal(Heating/CoolingRetnm) ❑Other(explainunder#21Remarks) PROM TO DESCRrn1TON(colar.haranesv,sail/rock type grain size,ere)
Date Well Started 6� /c— //�� V p 0 . ` _
4.Date Well(s)Completed: ' '/ ? well m#A AGE— 2 2 ,r ft 5-oft. ,✓tgy7 J �6:y 01�,.yi ,jh.. CQ�L
5a.Well Location:
Phone#: 6tb ft ;7i4 ft !?® , 7 kill(lleJ� lL-Aet '
.S+.ev ed a- k„d, kve �v e-le, , ft. ft __ . - ,/ ` �
Facility/OwnerNsme Facility ID#(if applir.Ahle) ft ft '` 1.1 i.:.- L. )
phi it rs c\c,,f pur 92e�ir, NC1
Physical Address,City,andZip ge.01.0 f ft' SEP r ,O�A 5
Y V a A Mw :2f5Tt�,;Pjcs ;S':'• •::'•': ._ z..';:. h lr:j^ fr:r.`7=u',"?r csi-a�a l:�F.`•S.U._..
County + �� Parcel Identification No.(PIN) ,���t''tolieti"' bA 6i4:(z/Ave:®o4 ci
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �`�I ���Q Lea ®�� `"`®/®
(if well field,one lart/long is sufficient) i i° 22.Certification: a
/5.- 4/11 fe N '91' 5 3`1 1%-) w
6.Is(are)the well(s): permanent or ❑Temporary Si:T. AIS. 4-fr
of Coed We Contractor Date
By signing 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 Aro 15A NCAC 02C.0100 or I5ANCAC 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.
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 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: 1 i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 476 (E') Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths p`different(example-3@M and 2(4100)
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"+" ,
11.Borehole diameter .6 (in.)Bit Off: 6a d� 24b:For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
- Program, MSC,Raleigh,NC 27699-1636
12.Well construction method:` &'&t/ ��'
cable,directpush,etc.) °� 24c.For Water Supply and Open�Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary, county environmental health department of the county where installed 0
• FOR WATER SUPPLY WELLS ONLY: • ti
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA �+
13a.Yield(gpm) �� Method of test: Permit Piogrem,1611 MSC,Raleigh,NC 27699-1611
o Date Site Visited: '
, 13b.Disinfection type: 70% hth Amount: OZ Site Visited By: 1
Form GW-1 fa,; ssp ,, ,. , North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: I
. 1 1 I .