GW1--03349_Well Construction - GW1_20230516

1 !;S CONSTRUCTION CORD(GW-1) For Internal Use Only:
—�
l;Well"Contractor Information: -
do d V 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name '1.37 ft. ln. ft. d[ j/P� C)Ve
`�'a d�J Cl�c.� O7 li
ex' ID
NC Well ContractcationNumber ��� ft I {t a7 ��� /�)
15,OUTER CASING(for multi-{cased wells)ORLINER(if am linable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TB10ENESS MATERIAL
ft ft. in.
.....,,NCompaayName 7 3 ^� 16.INNER CASING ORTUBINGfgeothermal closed-loop) [ Ze
"t 2.Well Construction Permit#: 3 =d 5'� FROM TO DIAMETER THICKNESS MATERIAL T
ii„jj List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) �1 fr• V'y ft In in. "1_ y/1 P� .,. 1
3.Well Use(check well use): ft ft. `x in. l➢ !
Water Supply Well: 17.SCREEN d
FROM TO DIAMETER SLOT SIZE THICI[NESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in. 7
:Geothermal(Heating/Cooling Supply) ('Residential Water Supply(single) . ft. ft. in.
❑Industrial/Comercial . DResidential Water Supply(shared) 1B.GROUT Z
m
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EM M PLACEMENT ETHOD Se AMOUNT .�
Non-Water Supply Well: 0 ft. vv�j ft. 2L41. C ' S GetAy-�I
DMonitoring :Recovery ft. ft.
Injection Well: ft. ft CA
:Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) CY;
:Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT �-
:Aquifer Test ❑Storenwater Drainage t ft.
❑Experimental Technology ❑Subsidence Control ft ft.
Cl Geothermal(Closed Loop) ❑Tracer 2D.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sell/rocktype,grain she,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
u r)j,� a ,{ a t. ^7� ft. �01
4.Date Well(s)Completed: -I d` t—CPJ Well ID#�A ? 3 7 G f `5�0 D ' .t{�(Vr‘1�Q,
Sa.Well Location: ®r> r 1 3 ' '5O �� ft. rike c:l ;-i
y° PPhone # �9 ft ft.
Facility/Owner Name d Facility ID#(if applicable) ft. ft. _m ��- -�
p_,� ® „ }-ty;to reel TP/Iv l�cil' ft. ft.
r Physical Address,City,and Zip L e. t- ZrQ C S'6 p g9 a d MAY I I= '7(19'� '- cil,
�r$�� 21.BEMAB S-
LVL�
Comity Parcel Identification No.(FIN) I nfy,:,:,s1 ^n i�r . 'l'7 Lira tY DV/Oiu'V
:ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 Imo 2- 7!5- N y'/ q4, 3 7?f w .
11—Xl—gN)
6.Is(are)the well(s): Permanent or ❑Temporary Signatn a of Certified ell Contractor Date •
By signing thisform,I hereby certjjfy that the wells)was(were)constructed in accordancewith
7.Is this a repair to an existing well: :Yes or d 0 15ANCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that weepy
If this is a repair,fill out known well construction information explain the nature of the of this record has been provided to the well owner.
repair under#2I remarks section or on the back of thisfonn 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 GVf 1 is nee (add'S Over'in Remarks Box).You may also attach additional pages if necessary.
cjed. Indicate TOTAL NUMBER of wells 'Set /
drilled: e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,2 0?Nr (ft) Submit this GW-1 within 30 days of well completion per the following: 1
For multiple wells list all depths If different(example-3Q200'and 2@I00�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level b elow top of casing: I I C (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: �'4 2.4b•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 push,etc.) 1
county environmental health department of the county where installed
FOR WATER SUPPLYWEI.rR ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA '
13a.Yield(gpm) 11 Method of test: es®ice Permit Program, MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: 3 OZ DATE SITE VISITED: J/"/4; 2-
Price!! , VISITED BY: ,VA
Form GW-1 linaDepattrnent of Environmental Quality-Division of Water Resources Revised 6_6 2D18