GW1--06942_Well Construction - GW1_20241119

WELL iL CONSTRUCTION RECORDRECORD(GW-4) For Internal Use Only: 1
EED
1.'ly lt'Contract Infor i'tion;"74/5 .
C4/ 19.WATER ZONES
FROM TO DESCRIPTION
Well Contractor ame 7/'/j ft. i ill ft. ifyLI. f-h,/•,e, /7C"'�
/ / Y ft.
v(( ft. i J ` rw L
NC Well Contractor Certification Number 15.OUTER CASING(formula-cased i'vells)OR LINER.(if ap licable)
YHDKJN WELL COMPANY,INC. FROM TO - I'DIAMETER : THICh'NESS MATERIAL
ft. ft. I I
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W 0 ' t 1 .4 23 FROM TO DIAMETER THICKNESS 1 MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) W ". 9,ft. bite' to. #ft'{J I1 I3 jt4 S
3.Well Use(check well use): ft. fr. 'n' 1 v i LI
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agtcultural OMunicipal/Public ft. N. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n. ft. in.
❑Industrial/Commercial . . ❑Residential Water Supply(shared) 18.GROUT
' ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEM NTMETROD&AMOUNT
Non-Water Supply Well: L rt. 502•ft. ,/I,0,ftzx P f& 1/ 7jl,
-\
❑Monitoring ❑Recovery ft. l�eft. 1/hJ is e4/" CV u'9�
irjection.Well:
ft. ft. •
D-.ouifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applx_rable)i,_,r;
DAquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft' ft. N V V 1 C !O24
❑�Experimental Technology ❑Subsidence Control ft. ft.
,x/
�'GeotherTnal(ClosedLoop) OTracer 20.DRILLING LOG(a Hach nd'ditional•sheetsifneceisary), "''"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRiPT10 (eoinr,harHi;isr,soil/rock type,Brain she,etc.)
© ft. -5 n• Scii K:
4.Date Well(s)Completed: f �1 Wel1ID# •_a3a. r5 ft. /), it. C/ . r7 '
wt.S �u¢Jd r,-•
Sa.1Ve]1Location: Phone # 1(cl •�1 S-/=v /�� ft ) ft. �� ��.
tlia h-- CC/Pl ' 1Zi4�G c &XJ�v� L l _J/ti it. C� it J ✓ Si C 1.
J /-'�hnl �/ �,t
n Faaccility/OwnerTNamc U.u y(jCy��f yK l rll>,yt M/(rf Jipp�'l a a1) 1 �) ft rj ft �./t /' `✓",I y �/�/11 ��d7� /�=f
�/, `'y� � J 1l�lJs G1h ru(/G�GI� Y G ft. ft.
Physical Address,City,and Zip C 5 ft. ft. .
1 21.REMARKS
r' BORES (2) DEPTH (SC0 r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( f ) DIA OF LOOPS (fJ
vol. (IfwcU field one tat/long is sufficient) 22.Certification: SDR OF LOOPS ( r i) 2-4-'=.
V ' 3.s, CO 3CC N 1 r. '7, 0 il-' ° w C � y�� f
� Sigoature of Certified Well Contractor Date /
6.Is(arc)the well(s): C�]'Permanent or ❑Temporary
�� By signing this form,I hereby certh55 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or If0Vo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If the is o 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 621 remarks section or on the bock 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 Iree4d. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 9., U' • 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Sal (ft.) Submit this GW-1 within 30 days of well completion per the following:
multiple wells list an depths if different(example-3 rQ200'and 2©100') P
r _,) ) 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 wow level is above casing,use"+"
11.Borehole diameter: Cr (in) Bit Off: LI 24b.For Injection Wells:Copy to'DWR,Underground Injection Control (lUC)
Program,1636 MSC,Raleigb,NC 27699-1636
AIR ROTARY I
1.2.Well construction method: 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) l�L C�*e�lt- Method of test:
V Permit Program,1611 MSC,Raleigh,NC 27699-1611
�tr
° OZ DATE SITE VISITED:
13b.Disinfection type: 70/°HTH Amount: -
VISITED BY:
PT-Z re.:
Fort Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources ', - • Revised 6-6-2018