GW1--06055_Well Construction - GW1_20230921

° --Il'CONSTR'TJCJTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor nfornation: ,
14 [ I on 4 C ire.- I- lg.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
Sft 3% ft Lc-
NC Well Contractor Certification Number
15.OUTER CASING(for multi-rase/wells)OR LINER(if a licable)
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER THICKNESS MATERIAL
ft. ft. 1 in.
• Company Name �j 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 G ! Zt FROM TO DIAMETER THICKNESS r TERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4. I ft 12 5 it �,06- ID. f p IR 0' V V�
3.Well Use(check well use): ft ft. in. 1�
Water Supply Well: .. 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. ie. L
❑Geothermal(Heating/Cooling Supply) piesidential Water Supply(single) it, ft, in. 0
❑lndustrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT =. mac,
❑Irrigation ❑Wells>100,000 GPD FROM d0�TO MATERIAL ATERIAL EMPLACEMENT METHOD detiNT
Non-Water Supply Well: ft. R. eetrim:1-G Cit r]® p0. fe!€11
• ❑Monitoring ❑Recovery it ft. w ! .f
Injection Well:
ft. ft •
❑Aquifer Recharge ❑Groundwater Remediation -
❑A uiferStor Storage ❑Salinity Barrier 19.SAND/GRAVELPACK(if applicable) •
q ag Recovery FROM •TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test • ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLINGLOG(attach additional sheets if necessary) _
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/recktypc Brain size etc)
a-23 a ft. Ian ". S'O.!"
4.Date Well Us)Completed: .• ("al Well JD P_Jr d3 I?' ft 3 p3 ft [vLCqe�
9iuy 0 l C l
Sa.Well Location: Phone # 76 - q-V Y
��9 ft ft . •
wi'i(<t Fick ?TA ®'-0 �.:�'3‘�t �. 9...A_
Faoii /OwnerNamedat Facility#(if applicable) ft. ft I'°q i<.�f F�\/ -)
►'2 /Atikayl�� �t, ,,� ft. ft. ,. . ._ �
Physical Address,City,and Zip �,C. W 3 Q 13 ft ft S E N :; 2023
21.REMARKS
e4Sli_e. )f:`;', :?tit s= +.:.,x.ua•..4.4ln:a;
County Parcel Identi£cation No.(PIN)
iN• C jtf.1r,;,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification: '
36 33. 115-9 Ngl 3(, R153 W 8 4 Q3
6.Is(are)the well(s):permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisfarm,I hereby cart*that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or AlCio 75ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner. -
repair underq#21 remarks section or on the back of this form.
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 Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
�9.Total well depth below land surface: 3 (ft') Submit this GW-1 within 30 days',of well completion per the following:
For multiple wells list all depths If different(example-3@200'and 2@100`)
24a. For All Wells: Original form.to Division of Water Resources (DWR),
10.Static water leer]below top of casing: L (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" I
Bit Off: '1 S 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: to (in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY I
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed .
FOR WATER SUPPLY WET.r S ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA •
13a:Yield(gpm) Method of test: �'et/j Permit Program, MSC,Raleigh,NC 27699-1611 _(
_ C$� oi
13b.Disinfection type: 7D%HTH OZ DATE SITE VISITED: / al
, i e Amount- pp '!r
. VISITED BY: V to
pr-i cP,
.• r.,....,_ i i onmental Quality-Divisinn of Wares Rn_snnrc,c RPvioe,i 6.46n1R'•