GW1--04409_Well Construction - GW1_20230710

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e-'oyvf3:,,i1 c`"���.TKTJC ITION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Jere/ t $ 16 14.WATER ZONES
Well Contractor Name 1 mom TO DESCRIPTION
ft. ft.
PL163p
'i ft. ft. t
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLINER(if ap limbic)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL CU
ft. ft. I in. 1
Company Name -
�c 16.INNER CASING OR TUBING(geothermal closed-loop) k""
2.Well Construction Permit#: A 6,� FROM TO DIAMETER THICKNESS -MATERIAL
List all applicable well construction petinirs(i.e.UIC,County,State,Variance,etc) 1C ft ft in.
3.Well Use(check well use): ft ft. in.
17.SCREEN C2
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) . ft ft. in.
❑lndustrial/Comrnercial ®❑_Residential Water Supply(shared) 1B.GROUT -
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOTINT -
Non-Water Supply Well: ® ft. ft.
❑Monitoring ❑Recovery ft. ft. _
Injection Well: ft. ft.
:Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD _
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Cont(ul ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,seillrock type,grin size,eta)
❑Geothermal(Heating/Cooling Return) DOther(explain under#f21 Remarks) -
4.Date Well(s)Completed: 6(03143 Well ID# 44e' '36 3y5'ft. too/ ft. Grow%
5a.WellLocation: Phone # 070414foo-�S‘C it ft _
ft. ft.
• 37e_ p.,rib"ley. _ _
Fam'lity/OwnerName Facility lD#(if applicable) ft ft �? is c.:,1 ,,j.p b '�f •,-y
.... g'4'g fits. i 44 24. Iv96+1.2.4(2f0 rir.i-5 ft. ft II (I n nnnn .
Physical Address,City,and Zip 6,1( �Lj F3 ft. ft - J L U L J
® ' L g. 21.RE.MARKS lrl;;;-m5.Jr,:1 ?,-.--.^.._�.., ,,fir
County ry�if vG Parcel Identifcation No.(PIN) 5.1/4 w
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,et 0 4...20-dg1acb 11.t.e.of te .ttt--
(if well felt],one let/long is sufficient) 22.Certifi ation:
_76, 3.,s-. 74' N Yl top ;gel 9 w 4 .i _tAi -, L11,3112
❑Tea or Signahlre of artifed Well Contractor Date
6.Is(are)the well(s): ermanent or p ary
�D By signing this/Om,I hereby certjfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: urea or nNo f Ip ev,_ �' 1 SANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown 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-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: d 24.SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: toO. (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 2©I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: V� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use'4" 6
11.Borehole diameter: 6 (in.) Bit Off: S.ei 7S 24b.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.) county environmental health department of the county where installed WI'
FOR WATER SUPPLY WEt.T.S 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) 2 Method of test: SP?IA
hpe 0..t
70%HTH oz DATE SITE VISITED: ' 'ia (( w `t
13b.Disinfection e: Amount: m
Pr1 cP_ r1TEDBY:
V A