GW1--04473_Well Construction - GW1_20230710

.:;",tlJ CONSTRUCTION RECORD D (GW-1) For Internal Use Only:
1.Well Contractor Information:
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r rD�-5 t i ...._1-1`-c,0,-e_ l (/ , 14.WATER ZONES
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Well Contractor Name r FROM TO ESCRIPTION
De- cr If' 15�ft. Ito ft. to 60';�
NC Well Contractor Certification Number 2g, ft, rQf ft. �� E
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
YADKIN WELL COMPANY,INC. FROM TO I)L&MErEA THICKNrE�ss MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: wS/4 F-0/ 9(l/ -2 D 2 3 FROM TO DIAMETER THLCIOVESs MATERIAL rtl
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft in.
3.Well Use(check well use): ft it. in. r
17.
N
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICI NFSs MATERIAL 3
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l esidential Water Supply(single) 7Z/
( g/ g PP Y) PP Y( ' g ) ft. ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT Z.
Non-Water Supply Well: ® ft' 9,PP ft" lvw f+rle cf Erg H y� , i' e A le-e.
❑Monitoring ❑Recovery ft. 77 ft. K ►a!
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
[Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
:Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heatin Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,aoiVmektype,grain size,ate.)
,---_ Q ® f• 46. ft Soifi S fri,p®se R®cA5
4.Date Well(s)Completed: /Jt ftt, Well ID# ,4h&C(3 g 64) ft. ar ft' 6� 'V:to- �; y�' got IC f .s '
5a.Well Location: Phone #32c.�7M•-0 y•i 6 if ft. "7ef^ ft (5av"a--- - /fr 1 d- H
,
/ t y wa,. Wdt. L i t 4 ft 9,21 ft 6 re...*- LA ye C Y v ok ii z-
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Facility/(O�wnerNamee I Facility ID#(if applicable) ft. ft - �- - -
2c.3 o(a t2-( �t3 rn�k-irluill./e, ft. ft. ". w.l.. .. '1_" ?.::2,.,
Physical Address,City,and Zip ft. ft I I I 1 n T i
KO,•1(1 D1 21.REMARKS
County Parcel Identification No.(PIN) In; +_• ' '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2.Certi cation:
3(, 12-W67%= N 8'0„ .7 1 kg,r w , zli)
r � .2
6.Is(are)the wells): rmanent or DTemporary a of Certified Well Contractor ate
k� signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1_190 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 under 1121 remarks section or on the back of this form. A`
23.Site diagram or additional well details: CA
You may use the back of this page to provide additional well construction info 1.:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GVjT-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlm Box).You may also attach additional pages if necessary. U
drilled: I 24.SUBMITTAL INSTRUCTIONS
(ft)9.Total well depth below land surface: �9
For multiple wells list all depths if different(example-3@200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 0 ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(f
If water level is above casing,use"+" h t' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter K., (in.) Bit Off: e<</cg 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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
13a.Yield(gpm) /� Method of test: 4 , �LT' Permit Program,1611 MSC,Raleigh,NC 27699-1611
.
13b.Disinfection type: 70%HTH
Amount: g oz DATE SITE VISITED: 2 - 21-2 3
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(-TIP BY: ®J!�
, Form GW-I nmental Quality-Division of Water Resources Revised 6-6-2018