_Well Construction - GW1_20230315 (50)

a..1-`L�CONSTR'UCT]IOON CORD (GW-1) For Internal Use Only:
1.Well Contractor Inforruntion:
3 ..e( ' iv, 14.WATER ZONES
Well Contractor me (RAFROM TO DESCRIPTION t
ft. , _ ft. ilP
s-7.).®4 ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable) r
YADKIN WELL COMPANY,INC. FROM TO _DIAivmTER TRIMNESS 1 MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: v �' �IJLJ FROM TO -DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) .�a ft' ? it (Fv�l�. in. 44'6, Pvt.
3.Well Use(check well use): ft. ft. in. [1._
Well: 17.SCREEN
Water Supply
FROM TO DIAMETER SLOT SIZE rmciINESs MATERIAL
❑Agricultural ❑^l unicipal/Public ft. ft. in. III
❑Geothermal(Heating/Cooling Supply) (FResidential Water Supply(single) • ft ft. in. 's.
Olndustrial/Commercial - DResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft g' ft /30,0,dgg.4:42, Pe4iCSC/
OMonitoring ❑Recovery ft. 91.,3'ft. 1�,-ph rietly �„°�eme�
Injection Well: ft, ft. �3 p'
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Test DStonnwater Drainage ft. IL
OExperimental Technology OSubsidence Contro_1 , ft. ft.
0 Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
L�" ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® TO DESCRIPTION(eider,hardness,sail/rock ryaG grain a ec�)
'' p� r ft 5-' ft. 5 Radek-,
4.Date Well(s)Completed: "1 T" 3 .Well ID# '\ I' •""1( (4 5- ft 'Weft. la:-w/ 44,1 bee,, Am:4e
IP 5a.Well Location: Phone#3,7X-7 tr 7- 6 Y9 ? ift�®'f. V" ft.
PI `{:° 45;r6i DDfk'°d •4v.
r►�I �./ ( c/cc ft 0 ft H:ri /•L Al O G" '
' ��Kta� �� aL€i`Jlre,
Facts ity/OwnerName Facility ID#(if applicable) gl,j0 ft' elb ftme/ f7 t'1 jp k er-0,,'z
•
13_ y,.,® L.--AlApif-4.,,,, raa ?CO ft. Ar)ef0 ft. pi eoi Air/ Af,410.3.440
Physical Address,'City,and Zap. ft ft. _.,__. .
p "y, tiler 21.REMARKS ` {
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAR V L�i L
(if well field,one lat/Iongis,sufficient) 22.Certification: .,..._. ::j 1i2,+
3 c' 2 3,t i>�® N W.`' 0`3 2:�n o' w ` ' %J _ U �' -®q 2.?
Sir,I►';*of e •Well Contractor Date
6.Is(are)the well(s):' ermanent or OTemporary
- By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or InNo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information cmd explain the nature of the of this record has been provided to the well owner.
repair under112l 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 ifnecessary.
drilled: ! 24.SUBMITTAL INSTRUCTIONS `(7,..
9.Total well depth below land surface: �v� � (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 c62'00'and 2(g100')
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,use"+"
11.Borehole diameter: (in) Bit Off: +,'�0 gS a- 24b.For Injection Wells: Copy to DWR,Underground Injection.Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-163 6
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed j‘,A
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA\6`
/f c�d F(ty Permit Program,1611 MSC,Raleigh,NC 27699-I611 "
13a.'Yield(gpm)_ Method of test: s
e• 70%HTH Amount OZ DATE SITE VISITED: ,/l- o �-4 See 1.-
13b.DisinfectiontYP
__ _ _ VISITED BY: D-3-6 6 cek