GW1--05186_Well Construction - GW1_20230814

Wi JL CiINSTRUCTIICN RECORD (GWV-L For Internal Use Only:
(.Well Contractor ilnf a'tion:
14.WATER ZONES
FROM TO DESCRTTION
Well Contractor Name j a`e ft. 1)3 ft. 3 &' ' f 12ei
5 to S-/�- `) F),ft. I93 ft C)d� diet
NC W Contractor Certification Number 15.OUTER CASING(for Multi-cased wells)OR LINER(if a licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 U g , 2 e FROM TO DIAMETER TH1cIINESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 4•I ft l_ l_ ft l.fJ 6 in. Yj, %� SPP a 1 .
3.Well Use(cbeck well use): ft. _ ft. in. "� 1
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in. _
❑Geotiiermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. O'
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑in-Igation ❑Wells>100,000 GPD FROM TO MATERIAL (� I EMPLACEMENT METHOD&AMOUNT
D
Non-Water Supply Well: ft. ft awl Chi rewii7
,
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer 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.
jt
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness,,slUroekrYP4 Brain sae,etc.)
7 a 9',7),j 0 ft. () ft. .Sit r
4.Date Well(s)Completed: Well INP-5lt al ftft" 6ei' 1�l-C NC c
5a.Well Location: Phone # 334-.�g.2-.1.�a ft. 11. ft /1 d AlL
ilk t J1.-2-ice.- 79 ft. 173 ft 5O-R. Oo lit )1/4-0C S
Fac 'ty/Owner Name Facility ID#(if applicable) l 13 ft' 39N ft 50 f�- j7 5
1-Iv! i r-& i d rtt®/t t� N._ F ft. ft. 'I l Z`�
Physical Address,city,and Zip a A�of q' ft. ft.
U n. 'e a 7'":."a
4,'"l 21.REMARKStlKS '"i^I�I-�+-,r t4 .i tY E r"
County Parcel Identifi cation No.(PIN) Wit�^'� �#" AUG G 1 -: z LJ
A
44
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ir'� r. : ^n �,�,, ,. I tD
(if well fold,one 1at/long is sufficient) 1/ 22.Cert
ification: .3
3 4, 1.2,22 C 4 N c i 14�P! 4•2® 9 W CSI,-r` :8, :a
6.Is(are)the well(s): Ofermanent or ❑Temporary Signature of Certified We acror Date
By signing thisform,I hereby certy5,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or o 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information d explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the bock of thislform.
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-11 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: �f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30�^ (ft') Submit this GW-1 within 30 days of well completion perthe following:
For multiple wells list all depths if different(example-3Q200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Li5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing use"+"
11.Borehole diameter: 'rP (in.) Bit Off: a / 6 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 km
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 6
(Le.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 DWI?,CCPCUA
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Cdd a 0 a V
13b.Disinfection type: 70%HTH Amount: IC) OZ DATE SITE VISITED: f `�1)-"2- 1t a
ISITED BY: !l�
Prire�a - 64
FormGW-1 I ental Quality-Division of Water Resources Revised 6-6-2018