_Well Construction - GW1_20230315 (68)

y RECORD d-GW-1 c For Internal Use Only:
1.Well Contractor Inforrantion:
CV V U..j e -S.Q y,01,-,e-J 1,. 14.WATER 2 S I
;Jell Contractor Name FROM TO DESCRIPTION
�5It- ft. Ph,,
ITC Well Contractor Certification Number IS.OUTER CASING forIRIff-eased wells OR LINER if a Ucable
YADKIN WELL COMPANY,INC. FROM To f� DIAMETER TMCIINEk MATERIAL
Company Name +1 ft. " ft 6 t 1,,
�s n 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:Ws A r- ®®i o lc FROM TO DIAMETER THICTINFSS I MATERIAL
List all applicable well construction permifs(i,e.UIC,County,State,Variance,etc-) ft. ft in.
3.Well Use(check well use): ft. fr. in.
SCREE,N
Water Supply Well: rnoM TO DIAMETER SLOT SIZE TEaOCVESS MATERIAL
❑Agricultural ❑MunicipdTublic ft.
❑ ft. In•
Geothermal(Heating/Cooling Supply) ®'Residential Water Supply(single) • it. ft. in.
❑Iudustrial/Commeroial ❑Residential Water Supply(shared) 18.GROUT
OUT
❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEhIENTMETHOD&AMOUNT
Non-Water Supply Well: 6 "' "' a +i,' 1 I^ e-1;
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SANTD/GRA.VEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E11ipLACEMENTMI' 01)H
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control & it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILL'INGLOG attach additional sheets if necessary)
❑Geothermal(Reating/CoolingRetum) ❑Other(explain unde fr. 15 it A r921 Remarks) FROM To DESCRIPTION �Icr,nardaes:,sciVroek a sac ice 11+'
4.Date Well(s)Completed: 0l1 Well ID# " LI 13 :It IS It -5 Sc-1 pr
5a.Well Location: - Phone V6 7 tile/
ft. t 1-,6 'TL,7A
it ft +plaa vt it a 7zr d
Fac*/CfwnerNiune Facility ID#(if applicable) 6-4 It ` 1® ft L di
16- 111Z r rah 9/l/CA, �I ssa �. `to ft. 4 ft t
Physical Address,City,and Zip ft it.
Va
County Parcel Ideri cation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M^P ' 1,.
(ifwell field,one lat/longis sufficient) 22.Certificatio V
6.Is(are)the well(s): ETP'ermanent or ❑Temporary Certified 4./.tt-.acr Date
signing fhisform'I hereby rectify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CgPlo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repalr,fdl out known well construction information and explain the nature of the of this this record has beenprovided 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 GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only i CyW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarics Box).You may also attach additional pages if necessary.
dulled / vr�� 24.SUBMITTAL INSTRUCTIONS
9.Total even depth below land surface: �Lc
(f-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths/fd�erent(erample-3()a 200'a100D
�C 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
Iftvafer level is above casing,use"+' �
if Borehole diameter (in.) Bit Off' 6 +®�� ?fib.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pwb,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
n Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) � Method of test: Ptl✓ 1�5� it. S*ft4L
70%HTH OZ DATE SITE VISITED: r ''�_ '1� S�t.�105)0.xa.�vuri L.
13b.Disinfection type: Amount:
VISITED BY: L) -