GW1--06047_Well Construction - GW1_20241011

- WELL CONSTRUCTION RECORD(GOV--11 . For Internal Use Only: a
I.Well Contractor Information:
_ d .d a 4tWA ZONEs;_ ..:.;:;. '. -_'S F1-* . .., .
FROM TO .•' _ DESCRIPTIONtis&
Well Contractor Nam '
•
•
5 72,4 ft. ; ft
NC Well Contractor Certification Number
;i15: M._.
*01:1 :CASING:(fo%multi:cased;averq:OR7 F 'i(ifai liatilef.;'.:;; `":: ...
Yadkin Well Company, Inc. FROM ,TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name ATM' 3;16sINNER?EASING.OR.IBA�JG(geothermal closedlaop)'••: ": : ,1'.Z?:;• ;.: .I: _
2.Well Construction Permit#: en/ S 7 go 9 FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 4 1 ft P 7�9 ft 6,12-.1-
P Q2-�in- j2 g)i pre,
3.Well Use(check well use): ft. ft in
alad(iE I::,r'...:.'....a,; _"' F.i IZ:z ,':i... ':�'.:Ci ::':=;« :a ',-
�'
Water Supply Well:
FROM -. TO DIAMETER SLOT SIZE -THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) .esidenfial Water Supply(single) ft. ft. in
Lilndustrial/Commemial ❑Residential Water Supply(shared) i,Agy _, ,. - „
❑Iuil ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 1(1 ft. '(3 .�;/r� two r /1
❑Monitoring ❑Recovery ft ft. lv Fd
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwatr:Remediation
1 519..SAND/GReLVEI7PACIOirifplictZile):=y ':: �`•;'3i:::1,::•.i:;:;+w: ..:; :':::r>:`.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' •
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑G.:othermal(Closed Loop) ❑Tracer i 20:DRItINGI;OG(afro•h"iidditioiiiI ilieets'idriecns`ary)t. .,'=•3.',y,.,.;. ,...
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soturock type,grain size,etc.) +
Date Well Started q- #� i `i /� �J O ft. - ca� ft 55,;
4.Date Well(s)Completed: 9/ PIC/Well TD#A,/f ®36 0 ($'ft ppqo•ft _�,_,r,° j cep /1 f4„. 1
5a.Well Location: Phone#:70I- y 0_ gslit s7,62eft y o 'ft ben eda rat.A. 4
P4 9 _St./kkr V v CL,kg f. ft.
ft.
Facility/Owner Name yy Facility ID#(if applicable) . .
�`C_R/ r Fri t/�`f (Dr 3C ems MG ft ft. 5 tiff [,f afi, °
�dl ft. ft.
Physical Address,City,and Zip ��`N(� r
_...,,.. - -_P('. . ;', 2QZ �. . . ... ..
SAt 2115`I2RM1721tR. ITT t_ [7 C
County Parcel Identification No.(PIN) 'ir,f,f-,:'.r,-,,;'-.-' :c,-. _-•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: • C3
S ." ) ` -1 N 'Rl o, a cie W / �.e/ -���� ....16.Is(are)the well(s):)(Permanent or ❑Temporary Si:�. ofCettified eli ontractor Date
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes or ?io ISA NCAC 02C.0100 or I5A NCAC 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 io the well owner.
repair under#21 remarks 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 GVV-1 is needed, Indicate TOTAL NUMBER of wells •(add'See Over'in Remarks Box).You may also attach additional pages if necessary. .
drilled: V 24.SUBMITTAL INSTRUCTIONS
a
9.Total well depth below land surface: g® (ft.) Submit this GW-1 within 30 days of well completionper the followin
For multiple wells list all depths if different(example-3 a@200'and 2@100') y P g:
10.Static water level below tap of casing: d9 m ( )ft 24a. For All Wells: Original form'to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)Bit Off: 51,9,�
24b.For Injection'Wells:Copy to DWR,Underground Injection Control(ILIC)
` o Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4 I f r�) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
1 1 • Permit Program,1611 MSC,Raleigh,NC 27699-1611 W
ha.Yield(gpm) q Method of test: / I
�+. Date Site Visited: 4[16/ 1 q
o11)
13b.Disinfection type: ���o hth Amount: 3® Oz Site Visited By: 1,16 ,,-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: