GW1--06061_Well Construction - GW1_20241011

`" WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ; : g...
' 1.Well Contractor1 Information:n 1 I
JNil Via IM bu 0 S . �.714`.'.varEitzomes'�z :-.:....r�.,. . .. ., . -. .
Well
�CofitraetorName / FROM TO ' I DESCRIPTION
( ,1 - l� I ft Z ft 30 4
0 , P P!!n o
ft. ft. I �eql !-1
NC Well Contractor Certification Number <:15 OUTEE;::G1.ASIt G'(for`multi`-"cased;we1Li5)`:OR IDNER(if:a"l11 1lef;:.' a. -.'. : %-
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
CO
44 ft. /A l f. [, y 1.5 m• s 0 P+ -L I p v c.
Company Name
�p �� iO t16 INNER:C•ASIN G01&TIIBvIPTG(geotliermalelo'se3lauP� y n ->= -.'' a ''-
2.Well Construction Permit#: !�' - FROM TO . DIAMETER THICKNESS _MATERIAL <
Lint all applicable well construction permits(ce.UIC Comity State Variance,etc.) ft ft in.
04
3.Well Use(check well rise): ft. ft. In `
Water Supply Well i i .N.Ct T: •=-P.', .q!;.:.;:.vA`..i ,,.:_=:-,:�:_::...._:::1: :::�, :;-1;
PP Y 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) rf18?,G11dUT' .`a.-:��.:u2 v.. - :•- _ k- '.--'-•: .i u
❑irrigation ❑Wells>100,000 GPD -FROM TO MATERIAL EMPLACEMENT METHOD&AMovNT
Non-Water Supply Well: C) ft. Z. S ft Bene A l 4-€. d 1 p S Po v-r
DMonitoring - DRecovery ft ft
Injection Well: ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation
i.i19 SAITD/CRA9-tGrArrww ap lej;:: .:,°,,_,';, ..;'Si -,..:-'=^:'_.. _ .
DAquifer Storage and Recovery ❑SaliniityBarrier FROM TO MATERIAL EMPLACEMENTMETHOD •
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology 0 Subsidence Control ft., ft
❑Geothermal(Closed Loop) OTracer ii2WDRI1;tINC4IAG:(attache'ddrtionaTslieetfti:necessary)s ::'cl= N.Yr}• °':`f,la
❑Geothermal(Heating/ oolingRetum ID FROM TO DESCRR'TION(wlor,hardness,saillroe1 type Brain SITE eta) `
�( ) (explain under#21 Remarks) w..
Date Well Started 1�5.-.$-t`� ��ryy .0 ft. S ft -- c 16 . d- h;.,>t.,.,•,0
4.Date Well(s)Completed:a^29 -t 9 Well DV l�g�Gd'353 sp (� ft 4 7 ft 0 a d: , _.
5a.Well.Location: Phone#:153 )530-P55 0 9 g ,ft. c c ft t/ra ,:+-e. O C T 1 1 CU24
Facility/OwnerName Facility iD#(if applicable) Z r® ft. It it ft U,�r( c.„'1(M ti..,• .1.).%`''10.0 v
�� S iur o e� ) W� $28650 G22 Z.GO ft' P4_,, -
PhysicalAddressjCity,andZip R. ft �J li +F]"�'-
Aileg tl'any a�9( 905O( h21 a2 ��RK.S`.; .-.. .- y ...., lvz..-,.'.-.. L. .... .-.. ....�:.( .�...._.:.... ..
County 4U Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: P1
(if well field,one lat./long is sufficient) 22.Certification:
3(a94-11041 I 0 N PSI.ltt .il lb?, w ( e) Oa-19 -VI
6.Is(are)the well(s): DPermanent or ❑Temporary 'fly turc of r eRiSed Well Contractor Date. '
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or P No ISANCAC 02C.010G or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known Well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#2I 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks.Box).You may also attach additional pages if necessary.
drilled: m /'J N 24.SUBMTTTAL INSTRUCTIONS
•
9.Total wen depth below land surface: / 6 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ffdii erent(example-3 20®and®211007�_,.r, rq
F 24a. For All Wells: Original form to Division of Water Resources (DWR), ®�J
10.Static water level below top of casing: 7., 5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 r
If water level is above casing use"+" W
11.Borehole diameter: 6. i 2 S r (in.)Bit Off: S e 9 y S 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
y� Program,1636 MSC,Raleigh,NC 27699-1636 N
12.Well construction method: 0 1 r Q 1 9p 1 H 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
FOR WATER SUPPLY'WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: : r Permit Program,1611 MSC,Raleigh,NC 27699-1611
70/°
° hth ag
Date Site Visited:
13b.Disinfection type: Amount: r oz Site Visited By:
t .
1 '
Form GW=1_ _ 45,_ _1, North Carolina Department ofEnvi Environmental Quality-Division of Water Resources Revised 6-6-2018
Price:_