GW1--03068_Well Construction - GW1_20230428

( y L CONSTRUCTION RECORD CORD tftGW-11) For Internal Use Only:
1
t.Well Contractor information:
Ca)Y
14.WATER ZONES
FROM TO DESCRIPTION
A /�
Well Contractor Name left• left' / 6Poli Cluck•
115 s i L tft. Q i,'('$ - /G Pei clew-
'NC Well Contactor Ce:tificationNumber 15,OUTER CASING(for multi-rased wells)ORLINER(if a Seattle)
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name ¢°� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 O of 5 8 FROM TO ,DIAMETER THICKNESS MATERIAL
List all applicable well construction penes(Le.UIC,County,Slate,Variance,etc) 4,1 ft. 1 O ft. I S a in. I46 3.1 17
ft. ft. in.
1Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICItNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) kResidential Water Supply(single) • ft. ft. in.
❑In dustriaUCommercial . [Xesidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT CA
Supply Well: ('ft. 3 ft. a,�i� ,1,-..tlky .t1.,
❑Monitoring ❑Recovery it ft. 0
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO - MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ' ft. t
DExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(calor,hardness,soil/rock typ c,grain size,etc.)
❑Geothermal(Heating/Cooling f�❑Other(explain uunder421 Remarks) ft. ft � ,i{1
4.Date Well(s)Completed: 3-a--).3 WellT# AAR 3 f 4, 5 ft. 1G ft 5!`C11>i-1-c
e Location: 10 ft. �d ft �J e6,4 P ip ,
sa.w Well Phone #�-�1�3 1?4E�13 ��,�
. I___Lrpg_b___Zakfiritz m-1,43 ,i
30 90 ft. to�a � l ov �
Facility/Owner Name C Facility lD#(if applicable) LIAO ft' 1 ao Y 5 -- dint 11 S
T Lh dames Pie 121^ ,4s-G3W ft. ft -,r-L.T.r ; �� L)
� _..
17.
Physical Address,City,an /a d Zip Gene,- A ?C 7 ft ft. .�. ii.,i e
�4/1- •21,RET APR TARICS R 2 8 2023
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I.i'S"d(.l;Li'..{a
(if well feld,one let/longissufficient) 22.Certifi ation:
3i$ !k, b/,0CeN g1 3 q , 1.33- w . �° -�,
signal-.o ertified Well Contactor a e
6.Is(are)the well(s): Permanent or ❑Temporary
By signing thisform,_Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or clitia 15A NCAC 02C.0100 or 15A MAC 02C.0200 Well Construction Standards and that a copy
If this Ls a repair,fhl out known well construction information an explain the nature of the of this record has been provided to the well owner.
repair underi.21 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 t W-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlo Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 a O 3 (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 2Q100�
75 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit 1617 MSC,Raleigh.NC 27699-1617
lfwater level Is above casing,use"+"11.Borehole diameter: 4 un.) Q
Bit Off: Cl 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: A" !
HTH Amount: 51 oZ DATE SITE VISITED: a-11-1Z -
13b.Disinfection type: 70% 011.
Fri re r VISITED BY: 03 B
-.,,., nmental Quality-Division of Water Resources Revised 6-6-2018