GW1--03115_Well Construction - GW1_20230428

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• 7ONSTK1tJC T LON 1'i SC'O (GW-1) For Internal Use Only:
• .ionfractor Information:
����I:R9" d 'ia 19.WATER ZONES •••���
Well Contractor Name
FROM TO DESCRIPTION p.J
114 ft (3 'ft. Saved O ,--te
ft. ft IP
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased wells)OR LINER(if a licable)
YADKIN WELL COMPANY,INC. • FROM TO DIAMETER THICKNESS MATERIAL
Company Name
p J h�•/ y-17 16. CASING ORTURING(geothermal closed-loop) `
2.Well Construction Permit#: / 7 FROM TO DIAMETER THICKNESS MATERIAL
List a!!applicable well construction permits(i.e.UIC,County,Slate,Variance,eta)
-1'1tt �q ft col x-in. spi2-1_1 puc,
IP
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural ❑Municipai/Public ft ft. • in. / i
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. s tT
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lnrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT
Non Water Supply Well: 0 ft. kir ft.
❑Monitoring ❑Recovery .
Injection Well: �� ft ��.ff. ���''°�tufty �II/Piz id
❑Aquifer Recharge ❑GroundwaterRemediation it
I9.SAPID/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OS slinky Barrier FROM "To MATERIAL fEMPLACEMENTMETHOD
❑Aquifer Test ❑Stonnwater Drainagef i fl
/,
❑Experimental Technology ❑Subsidence Control f(
DGeothennal(Closed Loop) OTracer 20.MILLING LOG(attach additional sheet ifnecessary)
❑Geothermal(Heating/CoolingRetum) DOther(explain under#21 Remarks) FROM TO. DESCRIPTION(catar,hardness,sosv,arxtypa_era;a:he etc.)
�/ D ft 90 ft S A:r
4.Date Well(s)Completed:3 a': 3 WeUT# P'., i.zigoft ya7. ff. p e_turiwtte
5a.Well Location:
/� ,t-g7' Phone # �O?(, 16-a, 41g ft. ft
Cy(ffe (11 gir .170c;ii ft. ft
FacwnerName Fe.ilitylD#(if applicable) ft ft. 37:e. . ' o,
4. 1- 7 (.!G'11 Tit!l{it l 1e 4L e ,Il it rote `� ft # ( �. �J 9....o rf -..i..✓
Physical Addicas,City,and zip ft ft. APR 2 8 2023
(if-dilly
21.REMARKS
County Parcel Identification No.(PIN) IlhfOf ic1 0n Pf�: ro Ursa
Gti".L C-,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one Iat/longis sufficient) 22.Certification:
4 3•Qt 174 N O�./d 5‘, 413/9 w
6.Is(are)the well(s): Permanent or ❑Temporary Sign of Ce Well Contractor Date
By signing thisform,Thereby car*that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fro 15A 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 and explain the nature of the of this record has been provided to the well owner.
repair underl21 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-I is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 03 ft.
For multiple wells list all depths different(example-3Q200'and 2@J00� ( ) Submit this GW-1 within 30 days of well completion per the following: �� /
if
50 24a. For All Wells: Original form to Division of Water Resources (DWR),`\9
ID.Static water level below top of casing: (ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 \(
Ifwater level is above casing,use"+"
11.Borehole diameter: 67 (in.) Bit Off: 5'_g7 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
AIR ROTARY Program,1636MSC,Raleigh,NC 27699-1636 �\
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to thy (
(i.e.auger,rotary,cable,direct push,eta.) county environmental health department of the county where installed
1
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing.over 100,000 GPD:Copy to DWR,CCPCUA
C Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) Method of test: �G/ G, V 1. A-E93
13b.Disinfection type: 70%HTH Amount: 410 r Oz DATE SITE VISITED: -rveA, , ....,
Pri re r ' _
VISITED BY: % 1aa.4JrN