GW1--06155_Well Construction - GW1_20241014

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=j' iELT.CONSTRUCTION RECORD(GW 1't For Internal Use Only: P
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1.Well Contractor Information: j� �t
' J �9 t >r/" 4 i g i i f'ii )�'� i 13- 5,lAe WATa2'ZONES�7::it;*•..;.:::. t•.. '. '•:. ( ::. /�
FROM TO DESCRIPTION
Well Contractor Name p rj.
1,.4��ft 6.1•
ft �j 0 Al A cr .
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.;� di • tL • it i �j
NC Well Contractor Certification Number
1:15:D1TIZIC&SINOVonilifti,rceiedNiells-7:01MINEEXtrip—Liraillif.`.:.:,-...": i
• - Yadkin Well Company, Inc. FROM TO Dwv1ETEx THIcitNESS MATERrnr.
�• R ft. 8 fl 4 ft 6 s' in.
ca �.
Company Name o k,StioINNFdt;C-ASING'.OBO�ING:(fietitlieimal'clo5e31oop] :.;:;.:>�.,.:, .
2.Well Construction Permit#: t 1 l "rR 1 FROM TO • - DIAMETER THICENESS MATERIAL •
List all applicable well consiruction permits(Le.UIC,Cowity,State,Variance.etc.) ft. ft. in. ‘,
3.Well Use(check well use): ft ft . ' in. t
Water Supply We : r:17�SCREE '•:c .r-t_ :=': :::;w_:27:.:,:- , ;.=.'��__��'.:.. ; •
Well: FROM TO .-t.,,.DIAMETER `,SLOT SIZE THICKIT SS MATERIAL. r
❑Agricultural ❑Municipal/Public ft. ft. in. •
09eothermal(Fieating/Cooling Supply) fittesidential Water Supply(single) ft ft in.
grIndustrial/Commercial ❑Residential Water Supply(shared) 0.S1',GKbil ..r`;': _
Olin ation O Wells>100,000 GPD FROM TO :-MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft /0 ft 1 b P4. ,'::t. c 11 A" r Pll'a i.r
OMonitoring ❑Recovery ft. it • Y
Injection Well: ft. • ft '
❑Aquifer Recharge .❑GroundwaterRemediation �. _ ,<..,.,,,, ,,;,;
j:19::5E:ND/G OYSI AG`IC{i line le): ..-_ .._:.".:,.:. .;,T.:___v.`: _ .
DAquiferSterage and Recovery ❑SalinityBarrier.•.. FROM TO MATERIAL EMPLACF.MENTMETHOD Lr
t7Aga:ferTest" ❑StoimivaterDrainage• ft. ft _ .
❑Experimental Technology 0 Subsidence Control ft ft. •
" .GGeothermal(Closed Loop) ❑Tra'r - 20 3101 CJ GT:OG.(itisici atlditillnaZ'slieetittfie di aiW::: ':l.I''l;Y2.,'.:.-.€.
RO FM To., DESCRIPTION(color,hardness,sowwrock type,grain size;etc..
❑Geotbetmal(HeatingiclOoling Tietnra) ❑Other(explain under#21 Remarks) I
Date Well Started i tY- _ II fr. 4'Or sr ®;f;'A•#1 -
4.Date Well(s)Completed:1 %. - 1`wanD#AA -'/3 7 60 ft 114., ft. 1 &i I. .
La.Well Location: h Phone#' y�o7-� ,/ �47 s' figs-ft. :', Qft' °I: t''_ C3 t'flux 't`
q �+6SX , 1,0 ft. ft.. `• T ��
• -�.:`60&K1/4 �r)(c L. 1 f2 Coe rvirei " `_': ... . - ` .
• Facility/OwnerName Facility ID#(if applicable)' •
ft . -"
it O L 1 1 Z.:.2024 •
•
. •'Physical AddressrCity,andZip a.. or3jn ft ..>: ft •. ir.,
•
Cott my b ,,, " -' , .. - Parcel ldentificationNo.(PIN) • - • '�
Sb.Latitude and longitude in degr.eeslminutes/seconds or decimal degrees: .
-
i (if well field,one IaUloag is sufficient) .v erhficati n. ii .c, 5 A k, .4 r ;
f .,4i4e, ,i je, cf; .._.•:). 1 ..;
'Signature of Certified Well Contractor Date '�--
6.Is(are)the well(s): l rermanent or ❑Temporary ' `t,r d/ .
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 PJNo 1SANeAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and ecp lain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis fonn. 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
(add See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOI?_.NUMBER of wells
drilled: / t 24.SUBMITTAL INSTRUCTIONS
9.Total well d pfh below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all dcp:hs if different(erample-3(g200'and i@l00) 1
aL
> ft 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,u a"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)-..,0
11.Borehole diameter: (in.)$It Off. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction roc'_'od: 'Z t`r l / 24c.For Water$upply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc,) I county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: B 24d.For Water WelIsproducing ver 100,000 GPD: Copy to DWR,CCPCUA
>q ., 4 F • Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7 4Q°' Method of test: 1 r�
.( Z. Date Site Visited: sip L,r e.LiI •
e 70% hth Amount: O • Site Visited By:
•13b.Disinfection type: — i i
•- . Form OW-1_ __ _ - -—North Crrolinn Depas rent of Environmental Quality-Division of Water Resources Revised 6-6-2018
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