GW1--04467_Well Construction - GW1_20230710

'---1717Ej L L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
g-Will Contractor Information: _
19.WATER ZONES
�� ® FROM TO DESCRIPTION
Well Contractor Name `
4S 5® P- _ et
463 ft. .1.2S G� t¢� SeJ
ft
NC Well Contractor Certification Number 15.OUTER CASING(foraiulti-rased weBsLORLINER(if a livable)
YADKIN WELL COMPANY,INC- FROM TO DIAMETER THICKNESS MATERLrL
ft ft. in.
Company Name J 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: (� U FROM l TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits 4e. C,County,State,Variance,eta) _T)- 1 I i t@,s! ft lo in. 10 f I
3.Well Use(check well use): ft. I ft. in.
17.SCREEN
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.
❑Industrial/Commercial . OResidential Water Supply(shared) 18.GROUT
❑irrigati0II ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT P
Non-Water Supply Well: D ft . 93 ft' btrildif5 ?aorta (it,
DMonitoring ❑Recovery ft ft
Injection Well: ft ft
DAquifer 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
❑Experimental Technology " ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 26.DIULLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(ender,hardness.soil/rock type,grain sire,etc.)
❑Geothermal(Healing/Cooling Return) ❑Other(explain under#21 Remarks) D ft ff ft O i`/ /sort/
e sena 4.Date Well(s)Completed:JP -'93 Well ID# MP S D 6- ter ft o�� ft- ,-Ft' BayY IN"'5a.WellLocation: Phone # 331;-t'Qq-Lef3/ fig ft 12)�ft- i I48h+9PbY g�a'
• -rho a / F 11 ft ft
' 014.5 ft, ft
Facility/OwnerName IN,
• Fay 1ityID#(if applicable)
Physical Address,City,and Zip `Tra#Kik U pc, A i)
ft ft ,V.L +'n... b s' '-.'
Mir VA e r 21.REMARKS hi -p 0 2023
County Parcel Identification No.(PIN)
Int3;'ii1:-1:i�i1 ,
Uri
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ur;
(if well field,one lat/long is sufficient) 22.Certification'
34 lg,t�4.7 N--% 1 Dl. 45-p0 w 1P®f5--47 j
6.Is(are)the well(s): lyermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or To 154 NCAC 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 of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this fonn.
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 Remarlm Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL 11NSTRUCTIONS -
9.Total well depth below land surface: 13® (ft) Submit this GW 1 within 30 days of well completion per the following:
Far multiple wells list all depths If different(example-3@200'and 2©IOOD
10.Static water level below top of casing: MSc) ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ft
)twofer level is above casing,use"+" t •q Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 5. 1®3 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA G
R Permit Program,1611 MSC,Raleigh,NC 27699-1611 l
13a.Yield(gpm) 1'1S Method of test: Q/r,
e- 70%HTH Amount: 3 t OZ _DATE SITEPVIS11'ED6 v I 2 3 ` 3
13b.Disinfeetion type:
Pri eP', I--
Form GW-1 '. Revised 6-6-2018