GW1--05337_Well Construction - GW1_20230818

,1G CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
• ...e., ;ontractor Infor;.Lion:
- •
afr&—t1519.WATER ZONES
1.
'Well Contractor Name 1,� a PROM TO DES in p-�
`.� ft. ft. j r6 i
NC Well Contactor Certification Number !.i
15.OUTER CASING(for Multi-cased wells)OR LINER(if ap licable) , 3"
YADKIN WELL COMPANY,INC. A U G 1 8 2023 FROM TO DIAMETER THICKNESS. g MATERIAL 1
in.
' Company Name Ifh`CiAii+ 1_:fl t�f.^(g ��.rRS 16.INNER CASING OR TUBING(geothermal closed-loop) �A
2.Well Construction Permit#: 1 �!'f DY Qi FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.(..C,County,State,Variance,etc.) 4 Q. l 9 ft. in. Le �pJ p V c V-
3.Well Use(check well use): - ! ft. ft. in. 9
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
icultural ❑Municipal/Public ft. ft. I .
rb❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METowisHOD&AMOUNT
Non Water Supply Well: it. 2 fG �
❑Monitoring ❑Recovery ft. ft. E
Injection Well: ft: ft.
❑Aquifer Recharge ❑Groundwater Remediation — 4
- 19.SAND/GRAVEL PACK(if applicable)
DAqmferStorage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD 4
❑Aquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,kirdness,"soiUrocktype,grain size,etc.)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 6--2 23 Well 1D# p-s-2 2 ft. ft
''5a.WellLocation: Phone# Jiglia—/Ga® f. 1`1 7 n �rl gran `
. Ilex/�� e 760: QR„SZ d J ft lj 22 ft- !- I --fri- z•eV°°ft.
Facility/Owner Name /� Facility ID#(if applicable)
.2165 0®ley fee_. td's'i*t-crh ft. . ft,
Physical Address,City,and ft. ft.
6 21 REMARKS `�
County C` tT�� Parcel IdentificationNo.(PIN) .>3140 °A Ihj cm4,4 e1- .. -
' '. tO
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �V d �� �-6 0°
(ifwell field,one lat/long is sufficient) 22.Certification:
, 4,. oS, 4 z9�o-S N /37 ode, 3-20/ ' . w 3.3
6.Is(are)thewell(s):I,ermanent or ❑Temporary Sign o Certifie Contractor Date-
By signing this form,I hereby cerhfy that the well(s)was(were)constructed in accordance with
1 Is this a repair to an existing well: eVes or i INe'r 2 eV' 154 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 na re of the of this record has been provided to the well owner.
repair under 1'21 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.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 Remarks Box).You may also attach additional pages if necessary.
drilled:- ;$--' 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: d�� (ft.) Submit this GW-1 within 30 days of well completion per the 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),
ID.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+.' / I -
11.Borehole diameter: ie, (in.) Bit Off: S a '�f� 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
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
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed g
4
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
a Permit Program, MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 Method of test: aft r c
c.
70%HTH
13b.Disinfection type: Amount: OZ DATE SITE VISITED: ;!'
W
Er-Lb . VISITED BY: AP
I=. Form fib Wnnmental Quality-Division of Water Resources Revised 6-6-2018