GW1--08012_Well Construction - GW1_20231214

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'-`7alt CONSTRUCTION'tJCTIION J,lCO (GW-2.) For Internal Use Only:
1.WeirContractor information: I .t-3
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4/1. 19.WATER ZONES I
Well Contractor Name FROM TO DISCRn?TlON
LIES® A . xrt. �7 t i s i 3 7 Co
lTC Well Contractor CertificationNumbcr 15.OUTER CASING-(for multi-cased wells)ORLINER if ap usable)
YADKIN WELL COMPANY,INC, PROM TO DLAMTtTER Tffi MATERIAL
ft, ft in. [//
Company Name 16. i :a' CA5III'IG OR T11BIN (geothermal do ed-loop) ,
2.Well Construction Permit#: 3 (et 31 0 ••`rM TO DIAMETER THICKNESS _MA.A.TER_IAL
List all applicable well construction permus(i.e.UIC,County,Slate,Variance,etc) 711
17. f. 31 it G./2 S in. S C T dr L/�
3.Well Use(cheek well use): / ft. ® in
Water Supply Well: FROM EN .
TO DIA l SLOT THICKNESS MA
❑Agricultural ❑Municipal/Public t.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, tit, in. 7
Dlndustrial/Commercial _ [Residential Water Supply(shared) /B.GROUT
❑In-igation ❑Wells>100,000 GPD FROM TO -MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft 2S• ft• 13 A ,)S 6`, ;'7 / II -log
['Monitoring [Recovery ft. `
Injection Well: . /�
❑Aquifer Recharge 0 Groundwater Remediation /
•19. /GRA PACK(if appli bid
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL rMPLACEMEN METHOD
['Aquifer Test 1 ❑Stormweter Drainage
❑Experimental Technology DSubsidence Control f. r
7
['Geothermal(Closed Loop) ❑Tracer 20. KILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/raektype,grain sire,etc.)
❑Geothermal(Heating/CoolingRetmn) ❑Other(explain under#21Remarks) Oft. 6 ft.
4.Date Well(s)Completed: i I'2/ Z, Well ID# 01o0 n t''gt,,JC LY ia '4i rei1 K
5a.yWellLocation: / �.�§/ Phone#: 54? i'c'r �00 20 as-h ft. 11: h-1. C�j�r� SOW— }oi,&.
• sipl e dt.te- as� 3d.Z ' 1'1�kg-/GYY,� hGr� Y�
FaciiitylOwnerName Facility]D#(ifapplicable) Y t/ /
5.7L ram, A'd. ft. it.
Physical Address,City,and Zip ft. ft. ;.a, °....'i,. ' is '',
14J� �j,� 21.REMARtcs DEC 1 i l023
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' " � `.:.
if well fiel one lat/longis sufficient U e A •-_;‘));
(' d, ) 22.Certification:
.( iv, tint IN vd .1/.2. 124? W �� •
.
6.Is(are)the well(s): Permanent or OTemporary Signature of Certified L.IviveWTl Con r Date
By signing thisfonn,I hereby certy,that the well(s)was(were)constructed in accordance with 5
7.Is this a repair to an existing well: ❑Yes or P Qo ISA NCAC 02C.0100 or ISA NCAC 02C.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 of this record has been provided to the well owner.
repair under Il2I remarks section or on the back ofthis fonn. It
23.Site diagram or additional well details:
B.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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: '� 24.SUBMITTAL INSTRUCTIONS 2
9.Total well depth below land surface: 3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d�erent(example-3(g200'and 2@100)
„U (ft) 74a. For All Wells: Original form to Division of Water Resources (DWR), I
10.Static water level top of casing: (!J Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+" 0 y
11.Borehole diameter: l� (in.) Bit Off: 6. ,G,6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY j
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
(i e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA r.
Permit Prograrn,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3) Method of test: /IP•
70%HTFI - OZ DATE SITE VISITED: h I/e " "'-
13b.Disinfection type: Amount: •
VISITED BY: </ .-
endrrri,eni ' uran<n.i e_e_7n1 o