GW1--06046_Well Construction - GW1_20241011

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W1=-.�._ _ .RI CT1I0N RECORD (G17-4) - For Internal Use Only: rt
1.Weil Contractor Information:
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Cr fl 4.44�!I1 14.WATER ZONES i I
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FROM TO DESCRIPTION .......
• Well Co:r actor Name ft. ft. 1 1 01(-1 5 A ft. ft. I I J
NC Wc':i:oncactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) 4
YADK,`WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL o+ft. ft. ; in. S
Compar,Name 16.INNER CASING OR TUBING(geothermal dosed-loop) Q)
2.Wel:'Construction Permit#: I wet)construction
0 (. e 6) 7 �� FROM TO DIAMETER TI�CIOfESs MATERIAL `l
` 3"
List o!! •plicable el1 construction permits(i.e.UIC,County,State,Variance,etc.) G ft. IOC,
ft. & , in. . in 18I4c.1. .s ice i
�.•%r'.li'Jse.(checkwell use): ft• fr. nn
17.SCREEN ,
VI'.s: r:=.upplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS - MATERIAL
Agricultural ❑Municipal/Public ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial . . ❑Residential Water Supply(shared) 18.GROUT
❑Ime:tic o ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No._+.' .;I. ..•'Yell: 0 ft. ciao ft. 76et Erb 16
bade S
OMon.::,._..o ❑Recovery ft. ft. I l
Injcc'i.•n Well: ft. ft.
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❑Agt. :er Recharge ❑Groundwater Remediation 1
19.SANDIGRAYEL PACK(if applicable)
❑Aql.er Storage and Recovery. ❑Salinity Barrier FROM TO MATERIAL Er&PLACEMENTMETHOD
❑Aq,•ierTest ❑StormwaterDrainage' ft. ft. 1
❑ :,imental Technology ❑Subsidence Control ft. ft. I
U Ge.'_'termal(Closed Loop) • ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc.)
❑Gee.hernial(Heating/CoolingRetum) ❑Other(explain under#21 Remarks)
0 ft' 1.9S ft. ,go l
CN . .4. 4.Dr :Well(s)Completed: q lit')34 Well ID# 12- ft. 400 ft. 6`ans
111 fS2$- 2J7- )/09 ft, ft.
°---/ Sa..T ell Location: Phone #bIgU AI S A.y pe V r- -
F-... -,[Owner Name Facility ID#(if applicable) ft. ft.
1100 /-1 L,.4..cFov A 13w, cl_9c. C? A Joy F4 tY ft. ft. 1 - .-
it-
PhysicalAddress,City,andZip4 a81955 ft. ft. Ir.`..,7,<.. ._ 7: P-r•^,s,r,.r.: ;I,,, -.....1
21.REMARKS Li a"•�=s'-'. ri
Couit+._ ' ...
Parcel Identif cation No.(PIN) BORES ( 1') DEPTH,• 1904 ' '• - - .
• 5b.I_al.. ._ .• • ,i,longitude in-degrees/minutes/seconds or decimal degrees: LOOPS PER BORE' ( l ) DIA OF LOOPS (( ¢
(if wc•;-field,one
rtat/long is sufficient) I T �q . 22.Certification: SDR OF LOOPS ( / 1 )
3%1',+ •-7•O 6 CD,9 N ?/J (2-.3 i9 w . . �ua� �S l
w . . 9I«J zy
6.Is Ire)the well(s): ermaneot or OTemporary Sigrnatur ofCe ed •Well Contractor Date
By signing thisform,I hereby cert(that the well(s)was(were)constructed in accordance with
7.Is his a repair•.to an existing well: ❑Yes or C]fTa ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If the :s a repair,fill out lmown well construction information and explain the nature of the of this record has been provided to the well owner.
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repo-under 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.F-,-Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
con:_action,only 1 W-1 is ieedpd. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 0 o .I . 24.SUBMITTAL INSTRUCTIONS
...T;tal well depth below land surface: '100 (ft.) Submit this GW-1 within 30 days of well completion per theuiwrriug:
F.
•r illiple wells list all depths if different(example-3 c@200•and 2 I00
N/ern► ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
:v 10. atic water level below top of casing: ! (ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwa:er level is above casing,use"+"
11.Borehole diameter: Cv (in.) Bit Off: 24b.For Injection Wells: Copy;to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636_
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12.Well consftuetrnn Lhethod: AIR ROTARY 2dc,For Water Supply'and Open-Loop Geothermal Return Wells:Copy to the
Lc ?e' rWary;cable,direct push,Mc.)(, county environmental health_department of the county where installed {�'
FO::WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA ,,
m 13a.Yield ) �
(gP 1 Permit Program,1611 MSC,Raleigh,NC 27699-I611
� Method of test: �' i
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
PT; r:e_ VISITED BY:
Fe:- jW-1 North Carolina Department of Environmental Quality-Division of Water Resources a...;,r,t F_F_7n1 a