GW1--05147_Well Construction - GW1_20230814

V -ONS TR'1tJCTION_RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CeDu-sQ.lJ p„49 r4-e_, L_ 19.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name �^ t
3D3 U ,g0 it-DO 9'4yciaeJfrsle he#
44
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIALLS
Company Name 4 t ft. 1 1 it. r/.{9.5 in. S pK 4( p v-�
i n L. 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: Pp NU L. 2®a 2 02 72.0 FROM TO ^DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.MC,County,Slate,Variance,etc) ft. ft. in.
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL cl
❑Agricultural ❑Municipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) Residential Water Supply(single) • ft. ft. in.
❑Industrial/Commercial ,�,7[1 idential Water Supply(shared) 18.GROUT
r, 1 r b*ells FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
['Irrigation r^a e - � ells>100,000 GPD 1 /
Non-Water Sup ly�P�'e111,../@.�° �l 0 ft az ft. ice,. . 1446 7J j/ ,'.r�.to I.q-e.�.
❑Moultoring !� A 702J ❑Recovery ft ft. f
Injection Well: 1.W - i
❑A erRech e >>r��FA' 'tlGroundwaterRemediation R ft
❑Aquifer Storaget+az`E1tRe o+E'.f-yes ' ❑Salinity Barrier FROM1VD TO/GRAYEL PACK(if Mapplicable) EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.soiUrncktype,grain she,ctn)
❑Geothermal(Heating/Cooling Ret un) DOther(explain under##21 Remarks) ft. e I
5 _ ll/ 4yI09 ft.D 2.� s. t Len i S/� /`--- -
4.Date Well(s)Completed:________ Well ID# AP '‘, C c S R' QP � at.�C + 4v�G7 J1 T'
5a.Well Location: Phone # / -30 _ �2 is f I ft g®�lk l e..,_ y 1 e�
. Amid o- 071 ft 7® ft. .f!r; I 4rs.�'' .{ Iv. ed/ .14
Facility/OwnerName Facility ID#(if applicable) 1`3�R' 3 ft gb / L dt- 4rS C-/ %.f-kilts d-
rk
ft. ft
Physical Address,City,and Zip ft ft.
Al Jetty 21.REMARKS
County a Parcel Identification No.(PIN) �✓ACk� I (b,- l b bp e J_v eST 9 5l -/580"&
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 00 E �� ®� r�S'�
(if well field,one I onus sufficient) 6 9 S. 3 ( 0 1.i cation:
'''' 6.424,J.e...._......
at
-4/,g0.23
6.Is(are)the well(s): termanent or ❑Temporary
e of Certified Well Contractor e
By signing thisfarm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or. -1144 1SANCAC 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 th.;. of this record has been provided to the well ownter
repair under 1121 remarks section or on the back of this forni.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the-came 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 (arid See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Io (ft') Submit this GW-1 within 3!!.day:of well completion per the following:
For multiple wells list all depths if different(example-3il�200'and 2@I00)
.2-.6 24a. For All Wells: Original form to Division of Water Resources (DWR),
ID.Static level below top of casing: V (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
',Twitter levell Is Is above casing,use"+" 6,673Bit Off: 24b.For Injection Wells: Copy tb DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: -- 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 7
(i.e.auger,rotary,cable,direct push,etc.) ,, county environmental health department of the county where installed
r
FOR WATER SUPPLY WE7.I S ONLY: t?Ar 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
li� Method of test:Rl(r %DO Permit Program,1611 MSC,Raleigh,NC 27699-1611 .4
o oz DATE SITE VISITED: g
13b.Disinfection type: 70/o HTH _ Amount:
- t.
SITED BY: OW Vd
Form GW- ality-Division of Water Resources Revised 6-6-2018