GW1--06058_Well Construction - GW1_20230921

Fr
�f`�oNsTT�'T:TtrvZl oN.t t ip ,(Gni-v-al For Internal Use Only:
1. l Contractor nformation: •
- r ��n . C�0�.1/� 14."WATER ZONES
Well Contractor Name FROM!" TO •
DESCRIPTION
st ft. A ft.. I ed 4+ i'ii 4�4,-
I� - .'1 90 ft. /0049 n• 4,. •
Y.
NC Well Contractor Certification Number 15.OUTER CASING(far triulfi-cased wells)OR LINER(if a ticable) ..
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft. ' ft. I in.
Company Name 2 r� 9 fA/� 16.INNER CASING OR TUBING(geothermal closed-loop)
• 2.Well Construction Permit#: f/ ! `ff�`� FROM TO DIAMETER THICKNESS MATERIAL Dec,List all applicable well construction permits(i.e.IBC,County,State,Yorionce,etc.) 4- l ft 53 ft. D a)co 'n. i`7 S C , ' P
3.Well;Use(check well use): ft. ft. in.
Water Supply Well: F SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) >4tResidential Water Supply(single) It. ft. iq.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation [ .-^ •'--.3-'I�IWe1fj�10'b�000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT/ - l
Non-Water Supply Well: I' i, -„'�1'L.t �4r >vv�g sar O ft. 1,1. ft O4n -un;4-& ra 10 S (dui.& %' ( e
❑Monitoring 2 f T32. ry it ft. t3 ft. 3T,l a-'1� .s ��1� QAP ilv1 e�
Injection Well: � r - fr. ft. _ /
❑Aquifer Recharge fi q. .Cron lefRemediation �!�I (r1 i'1.1
,;il 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recl3Va} u)iyJ )it"mityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stomiwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltroek type,gratin she,etc.)
OGeothermal(Heating/Cooling Return)tf ❑Other(explain under#21 Remarks)
f- I-493 } 6 ft. ?s ". 3-0 u l 1 0
4.Date Well(s)Completed: i1 R 7 Well ID# 4( ''?3 35-f- 3 e ft. r- +�C p by Li I•t. 1 t4/( 5
1 Ic.J ICI'
ft
5a.WellLocation: Phone # �j6 7 -(rS.�d Coo n^-r4 5.-t7 q
._r.,
A-ke_�� b; __ 3-13 Auwa s60" 100 f Oc(k. Srev
Fac111ty/OwncrName `aALi►n 08-hcl PL Facility ID#(if applicable) T.0 -- 9 5'0 1 t51i.t_ 0 r ' 9 ' - /�
/1i(c.,4d o p fs[:// Pei icc rs oh tat)
ion 3 ft. �u,T.y- 9 root 1'a-/ 1N 1i lick- Ce.A/1 '1-4. 3
• Physical Address,City,and Zip Wd/y ft* RO3 ft L 1,9)34-- 5rc y. s,6o._,}-
21.REMARKS
County Parcel Identification No.(PIN)
p 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
6d (if well
field,one laUlong is sufficient) y ® 22.Certification:
?•60 a 5r "3 ,Pil N �< �J D d tie
5 WofYIATAX;;) ECA. s)--ts -. 3
6.Is(are)the well(s)1ermanent or OTemporary Signature of Certified Well Contractor Date
C5By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
� 7.Is this a repair to an existing well: ❑Yes or itKo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
'- lfthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
R repair under t!2)'remai*s section or on the bock ofthfsfor,n. 23.Site diagram or additional well details:
6:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
11 construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
i drilled: '
//''�� t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (r L✓� l' (ft)
C.i For multiple wells list all depths If different(example-3©200'and2®700') Submit this GW 1 within 30 days of well completion per the following:
O /� ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
i 10.Static l Is water level below top of easing: / t (ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
y If water level is above casing,use"+" �!
r 11.Borehole diameter _ 6 (in.) Bit Off: b••0 1 li 24b.For Injection Wells: Copy to'DWR,Underground Injection Control(IUC)
a Program,1636 MSC,Raleigh,NC 27699-1636
w 1
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the i.
(i.e.auger.rotary,cable,direct push,etc.) county environmental health department of the county where installed
SUS,WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPO:Copy to DWR,CCPCUA e
(gptn) - Method of test: 1�d t✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611 4
ection type: 70%HTH Amount: 3 OZ DATE SITE VISITED: /"- " .� 0
.)
~ ` • VISITED BY: v8 •,
W"1°'Y'Y tental Quality-Division of Water Resources Revised 6-6-2018