GW1--06032_Well Construction - GW1_20241011

WEL_;,C,t S T R'U'CTION 13,E�COR''P (GW-1) - For Internal Use Only: m
1.Well contractor4 Informntion: I
lR
j] ,
JCC� kI�Cti c•[t I!� WATER ZONES i 8
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
I t ,
2'4S;,. 4 ft. ft. 1 1 0
NC Well Contactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) 7
YADKI(J WELL COMPANY,INC. FROM TO DIAMETER THICICtESS MATERIAL
ft. R. in. C3
. Company Name I6.INNER CASING OR TUBING(geothermal closed-loop) .7
2.Wel4Construction Permit it: 0 L 0073. FROM TO DIAMO.AJLR TIDCKNESS MATERIAL ,
List all dpplicable well construction permits(i.e.UIC,County,State,Variance,etc) ''.10 ft.
I Wti ft. G to. ,i!s9 .0+Q_er 54eep 3
D GIB I
3.vt)elhiliev,chtiok well use): ft. I ft. •
17.SCREEN
WaterrSupply Well:
FROM TO DIAMETER SLOT SIZE THICICNE55 MATERIAL
❑Agricultural • ' ❑Municipal/Public rt. ft. in. r7
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial . . ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT%.
Non:-Water Supply"Well: 0 it' 900 ft- 7lee,„,I Geri is b
❑Monitoring ❑Recovery ft. ft. 42.
Injection Well ft. ft.
❑Aquifer Recharge ' ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑AciiifcrTest ❑StormwaterDrainage ft. ft.
❑ix,erimenta)Technology ❑Subsidence Control ft. ft. .
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION trnina hardness,soil/rock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) d ft. �S ft ®I�aea v. '
4.Dace Well(s)Completed: flu I I Well DO AAr�" ��� (erg ft. �dV ft. 1 Creamily�� -�r7- �ro9 ft. ft.
0
Sa.1TJelleLocation': T -Phone #bstv:A .S,�• y,t{ev ft. ft Ec., > ,,
a 'ic . J co/fie.1/' • v t h.,.,t:.o'k...:.` .,' 5, . .
Facility/Owner Dlame Facility ID/I(if applicable) ft. ft
1100 ty i.,.'t'CPY`°A ef-, ..1fie, p& iyo,,4twit3C ft. ft. O C T i 1 2024
Physical Address,City,and Zip alb ft ft. iG::.:r,R. : .. ? ^ '' • Ti-
t) /' Q 21.REMARKS L"4 t.r" L..:i .�
.c,c e o
County:- , Parcel Identification No.(PIN)
BORES ( ) DEPTH •( Cat ' -
5b.Latitude and longitude in•degrees/minutes/seconds or decimal degrees: LOOPS PER BORE' ( � ) DIA OF LOOPS (�
(if well field,one lat/loag is sufficient) 22.Certification: SDR .OF LOOPS ( /r
3-7% 7g 6-7 if- N '/. 6 2 2C 3 W d W gJi,a jay
6.Is(are)the well(s): t "ermanent or OTemporary Sigoaturl of Cer fled Weli Contractor Date t
By signing this form,I hereby certy,that the well(s)was(were)constructed in c:cordance with
7:1;this a repair to an existing well: ❑Yes or ltf(o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If th ,is a repair,fill out latown 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 ofthisform.
23.Site diagram or additional well details:
8.Far 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 OW-1 is eidf d. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: Zj 7' • 24.SUBMITTAL INSTRUCTIONS '
9.,'j otlai well depth below land surface:d (ft.) Submit this GW-1 within 30 days;of well completion per the following:
For mullipft:wetlb list all tfepths if different(example-9 i©1200'a d 10
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: `�0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole'diameter: Co (in.) Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636MSC,Raleigh,NC 27699-1636
AIR ROTARY
.12.Well construction Lhethod: 24c.For Water Supply and Open loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary;cable,direct push,etc.) county environmental healthdepartinent of the county where installed yJ
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
(gpm)
NI( /A Permit Program,1611 MSC,Raleigh,i C 27699-1611
13a,Xieid m Method of test: ' V ,¢
XI
I3b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: -
P_.•; r.p_ VISITED BY:
F,::a GW-1 North Carolina Deoarttnent ofRnvirnnmenlal r),ulit,,_Iltot.t,,.,,.Fut.....n.........-. •. . .. -__._