GW1--06874_Well Construction - GW1_20241118

, 17,.. LL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
rt.)
1.We'd Contractor Information:
- 3 d. ; 11; ti. l ll -1Yr J 4 WATE$`ZONES :6 x" :.I , -r.':.: .. -s r• .,..•. .. .
FROM TO .•' DESCRIPTION
NMI Contractor Name , 0a
. 66 — # alit z
sl •
ft. 4:�6$0 ft
M R
NC Well Contractor Certification Number °15.•O „- 1tLINRR;
US�R:G-''A-SING'{foi�mril♦i e�iveIitis)`;O (if"'""7iFalilnM:,;f:.:::-
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company + 1 fr'• 9 9 ft 6,i7,5. 1.. S0a✓t P •p(
Name .
c •9 n .'+I63IIVNF.R:C9SING'OR;TQBIL�TG:(geutliermal'"cic`4.'e�laop)`•::::z:-;•::_:a'=. "'i`'`
2.Well Construction Permit#: 1 ( I9(,,-�2..#®zeg.-k ®� FROM TO . DIAMETER THICKNESS • MATERIAL
hist all applicable well construction permits(i.e.IlIG County,State,Variance,eta) ft. ft. ' , in.
3.Well Use(check well use): ft ft. in.
-Water Su I Well: - ri.rS'CREE :.`.M , 1 ; :e.;?s- -ems •. _•.-�2
pp Y FROM TO DIAMETER SLOT gr7.R THICKNESS MATERIAL
❑Agricultural ❑� M� unicipal/Public ft ft in.
OGeotheruiai(gearing/Cooling Supply) 61.1s esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ;p, ;,, ,: ar ,
❑Irrigation . ! :OWells>100,000 GPD FROM TO TERIAL" CEMENTMETAOD&AMOUNT
Non-Water Supply Well:'° -_...., ., ,v..� ft. Z.lit �6�/1;Vt. e ,,,,Ye, l,beAr
❑Monitoring ' NOV V 1 $. E l overy ft 4 ft
Injection Well: I U ft ft . .
❑A.quifer Recharge ., ,;perotmdwater Remediation
; '_. _ j'19.SAND/GR4.VarzF tVi£"sPpltcahle),:G..:-!.a..,,.:<A.,- :.1a.....0�5 z,<_`•:. •
❑Aquifer Storage and Recovery D.:•,: _..:17§allnity Barrier PROM TO MATERIAL EMPLACRMENTMETHOD •
°Aquifer Test ❑StormwaterDrainage ft ft ,
°Experimental Technology ❑Subsidence Control n•. ft
❑Geothermal(Closed Loop) ❑Tracer a0D - -'CS•'J;OG.(attaeh'additioual"she"ettldriecdisary)`i :+:."_^.=-7.=_.;":Z?,t::
❑Geothermal(Heating/CoolingRetum ❑Other(explain under#21 Remarks) FROM . TO' DESCRIPTION(color,hardness,sal/raek type grelu sue,eta)
Date Well Stalted0 - 0 II' 4-® ft. C ;
4.Date Well(s)Completed: I() -'31-'iM Well ID#/FAQ—foci I D ft go ft I-I� '(tr�r. it-
5a.Weil Location: S _ „` ne a•+°�Ge�Er O 1 ft, it r9 f drop 9P
11 a��a� • ACM ft 6Qj1 ft .J rl I-�.
Facility/Owner Name Facility 7D#(ff applicable) •ft'
Zoz E Pe4kCudPi L-"W- }•. l.e 1C . . ft .
Physical Address,City and Zip ft ft d
3 ' °i•2Ty22ENLA'1RRfi.,..,. ....�• r,•-vi;'e _ ,.:,,,i -, ....,.. .,.
e
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: 1" B '
(if well field,one lat/long is sufficient) , ertiEc lion:
. S C0 s- .6 W-i, N 6-0, 1 q b g ia W
Jf
6.Is(are)the well(s): ' m eranent or ❑Temporary I Lure of C ' d Well Contractor
/ signing this form,I hereby cern),that the wells)was(were),constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fi+lNo . 15ANCAC 02C.DI00 or ISANCdC 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 to the well owner.
repair under#21 remarks section or on the back of this farm. t
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).Yon may also attach additional pages if necessary.
drilled: a 24.SIIBMITTALINSTRUCT)ONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2 ct@+l00)
10.Static water level below top of casing: &I 0 (fti) 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•'+" .
t 24b.For Injection"Wells:Copy to!DWR,Underground Injection Control(1UC) .`
11.Borehole diameter: C (in.)J331t Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: t /04"01-p, 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: i
24d.Far Water Wells producing over 100,000 GPD: Copy to MR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
5c
13a.Yield(gpm) I 0 _Method of test: a r'
Date Site Visited: /®—I — �'ra
. 13b.Disinfection type: 7D% hth Amount: 1 ( OZ Site Visited By: 10 Urn
Form OW-1 North Carolina Department of EnvironmentalQuality-Division of Water Resources , Revised 6-6-2018