GW1--07501_Well Construction - GW1_20231120

s
- --WELL CONSTRUCTION RECORD(09V-1) For Internal Use Only: ('a
1,W2.92.1Licagier Information:
JarheS 14411 ,, 14.WATERZONES- _ c.
FROM TO DESCRIPTION
Well Contractor Name
G6 0 Star,.5*L S t� ' tm._ 1. Sy /ao
ft. CANC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(iron-hcable)
YADKIN WELL COMPANY,INC, $ FROM , _ TO DIAMHTE7 THICKNESS MA _
,ft. ft. in.
Company Name
" -16.11 CASING OR TUBING(geothermal closed-loop) _ . _ ._
2.Well Construction Permit#:
P FROM TO DIAMETER-,_ - '_ THICICNESS- _ G/
o f
List all applicable well construction permits(t e.UIC,County,State,Variance,etc.) _ �,!-!� I d(- _ft. (t(').5 ia, Sris'-a 1 _.1 1
3.Well Use(check well use): ft, _ ft. in. O
n.
Water Supply Well:,,, 17.SCREEN
FROM TO . DIA ,.SLOT S T HI S MA
❑Agricultural ❑Municipal/Publio ,
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft l ft in.
Olndustrial/Commercial . OResidential Water Supply(shared) 1B.GROUT
❑lrrlgation [Wells>100,000 GPD FROM. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . D f t. + 21 et Greet?:4t / -lays
❑Reoove
❑Monitoring rY f t. / -
Injection Well: ft i g,
❑Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) . _
❑Aquifer Storage and Recovery oSalinityBarrier FROM TO MATERIAL EMPLACET N OD_
OAquiferTest oStonnwaterDrainage' , f" 1 ft.
❑Experimental Technology OSubsidence Control ft. ; ft.
additional
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Rematk) FROM R TO'OG(attach DESl IP ION(color lewdness,eoiiirocktype,Oats]size,etc.)
c) p • '7-�3 P 48V 9 S I;S -
n
4.Date Weil]s Completed: � �' Well ID# D' 6 0 L t 1 r‘ti.,„*. J'"1 _�_„Sd'�1-_roc
5a.WellLncatiitsu: CC r,65A Phone#-1I4-zia2-.Z3 f 16n f L ft.uy'O2 .d Ob j YtG� w;d4,.Qu u/Se',r
��q AA UePe-044 •de/"r Lj11 ('CC (1 VIL. $l ` vv
Faciiity/OwnerNamd Facility (if applicable) nLV`F ft- .l fqp-" I,y1;y y,P s' l -_ -
717 .Sri lomi.k ie Rd. F, ` f-an gig/ .6b x, bra- b"1 Ste_
sical Address City;,and Zip p' C T. , -
Phy .. Lest lri,N
(eOwp,. a���kS -Zg-Z S-O�U°J 23.REMARKS M
-County Parcel Identification No.(FIN) NOV +1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - -- --
(if well field,one lat/long is sufficient) �� 22.Certification:_ In;`. . . • -J i',, •
3 G D. '?7.16 N 7S I .3 gi / f' �r ^ /J>�l '� �� �y� II - 1 3
Signature of Certified Well onClractor Date
6.Is(are)the4tvell(s): iermanent or pTeinporary
By signingthlsform,I hereby certify that the well(s)was(were),constructed In accordance with
7.Is this a repair to an existing well: OYesi or 1 o this record C.0)0nor I SA Nto Ct 02C%.0200 Well Conitruction,Standards and that a copy
dd ISANCAC 02C.01
Ifthis is a repair,fill out known well construction information an explain the nature of the of P owner.
repair under#21 remarks section or on the back ofthisform. 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 i)ceded.Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. (A
drilled: L 24.SUBMITTAL INSTRUCTIONS 0
9.Total well depth below land surface: __ CO 4 L-- (ft.)
For multiple wells list all depths if different(example-3©2(f0'and 2@100'. Submit this GW-1 within 30 days of well completion per the following: CO
�� (R) 24a. For All_Wells: Original,form,to Division of Water Resources (DWR), 3
10.Static water level below top of casing: Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617 P.
Ifwater level Is above casing use"+" I
(in
Bit OtiC-�•.0 a G [i 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC) 1
11.Borehole diameter: .) - Program,1636 MSC,Raleigh,NC'27699-163 6 _
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geotirerma4Return Wells:Copy to the 1 I
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed eO
FOR WATER SUPPLY WELLS ONLY: •1
24d.For Water Wells producing over•100,000 GPD:Copy to DWR,CCPCUA
Permit Progrant;,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) �� r. MOM&oftest: a6'(✓' -
70%HTH OZ DATE SITE VISITED:- I ��'Q s 3
13b.Disinfection type: Amount: '9 Q 1
i t VISITED BY: _ u - -•-- -- - - --