GW1-2023-01930_Well Construction - GW1_20230222

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,I,+CONSTRUC ION I '''CORD(GW-i1) For Internal Use Only:
1.Well Contractor Information:
del 14.WATER ZONES ,►�
Well Contractor a Enons TO DESCRIPTION
vaft p.sb ft tre♦". 9.8 S"-'r 6"7 5' 3
NC Well Contractor Certification Number • 3/0 f 41° ft / �
15.OUTER CASING•(for niulti-casa0'Iyells)OR LINER(if aptlicable)
YADKIN WELL COMPANY,INC. FROM TO t))L4TPZ
ME THICKNESS I MATERIAL
Company Name ft. ft. in. C-
/ 75(craa 16)NNER CASING OR TUBING(geothermal closed-loop) 02.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL (.a
List all applicable well construction permits [SC,County,State,Variance,etc) (G% fJIJ� Ai�/ ft. fi e ft ' it?rrn te, -d-d r
3.Well Use(check well use): ( H 7 ft,
Water Supply Well: 17.SCREEN
CllltIIral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
D ❑Municipal/Public ft ft io
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
_ ft, ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared)
❑Irri anon 1B.GROUT
g ❑Wells>100,000 GPD FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: Q ft.
['Monitoringnitoring ❑Recovery 5 ft. 6eH` /" u���
Injection Well: ft r3� /7�iMd-ggAfv pt/p•Z p
❑Aquifer Recharge ['Groundwater Remediation , ft. t J
❑Aquifer Storage and Recovery ❑salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLA.C.EMENTMETHOD
DAquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. it W
❑Geothermal(Closed Loop). ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saVrocktype,man sae,etc.)
o ft• form SW/
4.Date Well(s)Completed: /1-'i P7 Well DM .}�/ r 3 f ,®3-ft a® A
51t PI nsi4, /A.�'Or � K
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5a.Well Location: Phone # / I`f`3-43.5.0�� 3 3 'ft Pi,� Tee i� d
• 1t/ a f` '1, ft ft: je�Z ��` p
Facility/OwnerName Facility ID#(if applicable) ft ft
JJr f n
• �a (o ao�J1T �l�E+ �y iaN�+dS/11ti r ft. ft. I.-..ti; " � :�b ',��n. e-�
Physical Address,Cityy,,and zip i ft ft
Af _`I[tit,. FL f1 n n nrin..
((LL 4fJJ' Y 21.REMARKS F �-U 2 2 L U L 3
County Parcel Identification No.(PIN)
r`r 1, -sa, ' ^��J ..- ..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ���r
(if well field,one lett/llongis sufficient) y► �y 22.Certification:
yL 5
7, '/4'3 O N 1 /li6'fv. W .
6, /-f adi3
6.Is(are)the well(s): permanent or OTemporary Sign Certified ell Contractor Date
By signing thisform,Thereby certf&that the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or To I5ANCAC 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 explain the nature of the ofthis record has been provided to the well owner.
repair under il21 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 G71 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 32-3
For multiple wells list all depths Ifcb erent(example-3@200'and 2Q100� ( ) Submit this GW-1 within 30 days of well completion per the following:
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10.Static water Ieve]below top of casing: 6® c (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), 1�
ifwater level Is above casing,use"+" / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 W
11.Borehole diameter: 6 (n_) Bit Off: L7r 050 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
AIR ROTARY •
Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.anger,rotary,cable,direct path,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) 90 Method of test: , V Penult Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: 70/o HTH Amount: % OZ DATE SITE VISITED: ii"g`z 'L "' Z 7�'Z Z