GW1--06250_Well Construction - GW1_20230925

-W----lL CCONS Klf_ICTION '1 ECO1 ' (GWV-11) For Internal Use Only:
I.Well Contractor Inforn "on:
t-,U,5,6-- -c(to 0 1 19.WATER ZONES ; i
Well Contractor Name 1 i FROM TO DESCRIPTION
aac ft Pa0- tt. ! 6� mI
C)3% ft. ft. 1
NC Well Contractor CertificatirmNumber 15.OUTER CASING•(for multi-casedrwelis)OR LINER(if ap linable)
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER THICKNESS MATERIAL •m
P Y 1 ft.' �1 ft-- t433 in. SPi_a I it--.
Company Name
3,(.r elev.�0-r 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: c,i 13 S 9 2 - 221 2-2 _FROM _ TO ,DIAMETER THICKNESS MATERIAL CA
List all applicable well construction permits(l c.UIC,County,Slate,Variance.etc) ft ft _ iu. rk3
3.Well Use(check well use): ft. ft" 'n" d
17.SCREEN
Z.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft, ft. in.
❑Geotherm M
al(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. ��ry
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT t_",
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C> It. g.3 ft. 6rJfa' t/l.'(( 61 cryck i. /1 aC'�. "� -GI
DMonitoring is'1:::::Ilk;� `Oli�ec)very ft. ft. 03 /�a j S ,�aish/
Injection Well: i..- ..r k" •
ft, ft.
❑Aquifer Recharge 02 lGroundwater Remediation
P v v 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Re overy OSAWily Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test into "^ 'J r `„u rmwater Drain ft ft- ,
q or;r =;, s age
❑Experimental Technology r"+j LI ❑Subsidence Control ft. ft.
0 Geothermal(CIosed Loop) ❑Tracer 20.MULLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Re i) ❑Othe (explain under#21 Remarks) FROM TO DESCRIPTION color,hardness.smVroektype grain sue etc)
S4 ►-�l ,,,. J�,Fig3 �L b ft. y/9 ft. S C+; r +- 1-d®s.c .5 4-a �s
4.Date Well(s)Completed:/)1/144 371a?Well ID# 4kP-2.2C Deft. dl_- ft g/e,,.b�f C ie 6..(6 dory y k.- L.A-g�p5 IS
Sa..WellLocation: Phone # 3.3G- y z . C7 1 5 ft 5 1ft. t3'"' n tl-i 6S-"�-y f f Ax `It4F� "'C9
ft
Facility/OwnerName ` p Facility`ID#(if applicable)) ' R ,
2 000 a Sir 1-eticAl J te 1 k tptud(-e,
Physical Address,City,and Zip
ft ft.
I,(�,,(JCX ii,►%` 21.REMARKS oQ
County Parcel Identification No.(PIN) P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees p�
(if well field,one 1at/long is sufficient) 22.Cer:I cation: c ) C�
3�' I(� N RO® Y.Z_ �-YY - l71 44ci b51/9 :4
6.Is(are)the well(s): ermanent or OTemporary Si: of Certified Well Contractor Date
_� fining thisform,I hereby cert�that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I AiVo ANGIC 0.2C.0100 or l5A NCAC b2C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the well olsnter .0
repair under#21 remarks section or on the back of thisform. •
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 tutu
construction,only 1 GW-1;;s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlts Box).You may also attach additional pages if necessary.
drilled: ! 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: g/f . (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')
11 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ® (ft') Information Processing Unit,161,7 MSC,Raleigh,NC 27699-1617
ifwater level is above casing,use"+"
Bit Off: 5 t 7 72e 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(in.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
1
FOR WATER SUPPLY WE7.Y S ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to WR,CCP. UA
/� ��„ Permit Program,1611 MSC,Raleigh,NC 27699-1611 .5 `
13a.Yield(gpm) Method of test: 14
/ I oz DATE SITE VISITED: 0 a.+I( - 2 Cle �
70%HTHill13b.Disinfection type: Amount: yy
Prir�r�el �� 1-' -Q 2S
VISITED BY: OC///�S
I _ c.,.,,.1uW_1 I nrnental Ouality-Divisinn of WaterRecnu,ces. It evtced 6-6.3n1a