GW1--07530_Well Construction - GW1_20231120

6m^ " ` :ONSSTJR1EETCT11ION RECORD(GW-f) For Internal Use Only: •
4�]
--- . ell Orin ractor Information: - '
ti
(..Oa.V.k C S 19.WATER ZONES
FROM TO DESCRIPTION .2.-"AV'ellContractorName .SWt. S30 ft. aPM 3
'P' LI 6.4 A ft ft. b
•
NC Well Contractor Certification Number 15.OUTER CASING(for mnnti-cased'wells)ORLINFR(if ap licable)
YADKIN WELL COMPANY,,INC. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft in.
Company Name /J 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Weil Construction Permit#: Et 't /30 5 -FROM TO DIAMETER THICIINESS Mack Steel
List all applicable well construction permits(i a C,County,State,Variance,etc) T/1 ft �Q it . 7 in, .'.So bl
ft ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: morn TO ®DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMumicipal/Publio ft. ft. in.
OGeothermal(Heating/Cooling Supply) ittiResidential Water Supply(single) • ft. ft. in.
Olndustrial/Commercial . OResidential Water Supply(shared) 18.GROUT
Ohrigation OWells>100,000 GPD FROM TO MATERIAL EIVMELACEMENTMETHOD&AMOUNT
Non-Water Supply Well: n ft. 3 fr. 1401ire flu 5 ,fouled *gS
OMonitoring ORecovery 3 ft' 20 ft- CLielt Gsoai gimp a 3 bGSS
Injection Well: ft. ft.
OAquiferRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK inapplicable)
❑Aquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft ft.
OExperimenta]Tecbnology OSubsidence Control ft. it. .
OGeothermal(Closed Loop) OTracer 20.DRIII.NGLOG(attach additional sheets if necessary)•
FROM TO DESCRIPTION(color,hardness,scarock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) U ft. r9 ft. Sa 1
V 4:Date Well(s)Completed: 1°11912.3 WellID#"f/'r{.r - 33/ r9 it• To ft' Grans 1-ftP
1.�"sa.Well Location: l4:tn Phone # 336-67a-41`66-1. SO ft ev° ft 'JOiJ
3 it. 7G2 Gran1}r
i r' A. /11l a.H /1,t:/i./ z.s a7'v)A t`�'" / '!'t►C.`Jr E E ft. ft.
I` fop Facility/OwneName Facility ID#(if - al,e)C iAV-•, -,, 'h:._ Y "".
LA ,p QJM1 v �� ft. ft r r n
D_W e i e ACV e t r ft ft �UV 2 2Q23
Physical Address,City,and Zip v V 16�g
t X® 21.REMAI2ICS .
County Parce cation No.(PIN) r;t ^ . i r.'P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
Sign of Codified Well Contractor Date
6,Is(are)the well(s).16Permanent or OTemporary
By signing thisfarm,I hereby certfti that the walks)was(were)constructed in accordance with
7.Is this a repair to an existingwelI: ❑Yes or eigo 1SANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy•fthis is a repair,fdl out known well construction information and explain the nature of the ofthis record has been provided to the well owner. ft
repair under 1121 remarks section or on the back of thisform. 23.Site diagram or additional well details: GT
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 (xi
construction,only 1 GW-1 is nyeeded, Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:. t 24.SUBMITTAL INSTRUCTIONS --
9.Total well depth below land surface: 1'7C'a (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths IIfd(erent(example-3@200'and2(01000
I40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing; Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
(• ) Bit Off: Se 935 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: on.) Program,1636 MSC,Raleigh,NC 27699-1636
'l o auger,
construction method:
AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the`
(i.e.auge,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWI?,CCPCUAL
J �`� • • Permit Program,1611 MSC,Raleigh,NC 27699-1611 (v
13a.Yield(gpm) A Method of test: I cy
13b.Disinfection type: 70%° HTH Amount: 6 !OZ DATE SITE VISITED: 6, 7-( 2_'
Revised 6-6 201 S