GW1--06979_Well Construction - GW1_20231027

--- ,vr1 ,L CONSTRUCTION RECORD (GW-1l For Internal Use Only:
1.Wets Contractor Information: I ;
'j"--C3 VIALt ,\97 19.WATER ZONES O�
FROM TO DESCRIPTION
Well Contractor N i Ve tt /60 °ft .(
s'7�-A 737 ft• ;,39 ft , e E
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased ells)ORLINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER THICKNESS MATERIAL iJ
ft. ft. I in.
)13
Company Name , p 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Consh uction Permit#: ; S'cop 4d.2.2. g' FROM TO DIAhlI°rER THICKNESS MATERIAL
List all applicable well construction permits(La.VIt County,Slate,Variance,eta) ' I " TE ft L l>r in. a5 p/Z-( P v 0
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
. g
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) • ft. ft in. PO
❑Industrial/Commereial . 6Residential Water Supply(shared) 18.GROUT s
❑in-igation ❑Wells>I0D,000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. c"r ft. Bore ti:pi ?ezore®
OMonitoring ORecovery S- ft 6,t° ft f-?-Sic P ei el
Injection Well: ft. ft °
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD"
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft It.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Coo g Return) ❑LIther(explain under#-4`' o '• ) FROM TO DESCRIPTION{color,harduevs,'soiltrock type groin size,etc)
4.Date Well(s)Completed:A'`91 ��Well ID#(-[�T p' "" 1 0 ft. f 70 't� n '
5a.Well Location: Phone # '/QT%6 /7•?•�,T /18 ft � 03'ft. SR rS �e7 tea W,r
qe
J 2 4 'GLY`f b U'O h L4/e-.r ft it ;
Fam7ity/OwnerName Facility ID#(if applicable) '' ft. ft .. .
L. e e , ft. ft. '
Physical Address,City.and 4NC ��(p(p ft ft ` a u!`lr .._'4__,
1 21.REMARKS - .N t'
{ '-!!eghan (1(:T 2 7 2023
County V / Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ''' '2'In't
(if well field,one lat/long is sufficient) 22.Certification: lr.v"1 y G:V -1tY .
3 & 33.-'6'66 N 2 I d$r co Lod- W ,, .#:A/fletie • lit " e3
6.Is(are)the weIl(s): permanent or ❑Temporary Si a of C ...ed Well Contractor Date
By signing thisform,Ihereby certfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or vito 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy 5
If this is a repair,fill out;mown well construction information adcrerplain the nature of the':-, ofthis record has been provided to the well owner.
repair under k21 remarks section or on the back of this lam 23.Site diagram or additional-well details: �t
You may use the back of this page to provide additional well construction info v
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages it-necessary. pl
qq
drilled: l 24.SUBMITTAL INSTRUCTIONS r-
0
9.Total well depth below land surfacer (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 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR), E
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" yy ,..
11.Borehole diameter: (in.) Bit Off: �v+0 5 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) C
Program,1636 MSC,Raleigh,NC 27699-1636CP
AIR ROTARY i
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 9,
(i.e.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed 0
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
a� r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) • Method of test: Q Y .I
13b.Disinfection type:
70%HTH Amount: iet oZ DATE SITE VISITED: / ~I 4
1 p .
11 VISITED BY: V A
pa Department of Environmental Quality-Division of Water Resources Revised 6-6-2018