GW1--03280_Well Construction - GW1_20240528

`'�NEL L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
..Se.cc/ LJ O,4k-'AS 19.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. L 5-Vt. f G Pry,
. a y, A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a ticable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
4(7�J '1 FROM TO DIAMETER TH1IICCIINFSS MATERIAL
Li Well Constructionbwell Permit#: 7` l v Jft. � I ft. / 1t.1 in. 5t./�o�I PVc
List all applicable construction per us(i.e. UIC,County,State,Variance,etc.) �( ' C� -_
ft. ft. in.
3.Well Use(check well use):
-
17.SCREEN
Water Supply Well: FROM TO DIAMETER-SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Obligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 3 f. poi, P[j POV o-J 3 649S
❑Monitoring ❑Recovery 3 ft. a`I ft. OvtticIJro Pvw reel -I 613S'
Injection Well: ft. ft. l
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMI:NTMETHOD
❑Aquifer Test ❑Storrnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUroek type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft I ff. sOt
y►22Iy d -
4.Date Well(s)Completed: y I2�13'! Well ID#AA P.-�4p 8 1 10 ft 802 ft- 6,Q�1
ft. ft.
5a.Well Location: Phone # II 9-G/0-Ltgq
ft. ft
j i-v,vy P t'ft ft. ft.
Facility/Owner Naive Facility ID#(if applicable) :' r
161L 3 d 40 G fP"'44 4>r. W a..i 4- 31:IfttlYi ft. A
Physical Address,City,and Zip NC j cil MAY j. s 2024
t� 1 v 21.REMARKS
S �'
County Parcel Identification No.(PIN) a/y/-1 med 1f j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Said,one lat/long is sufficient) 22.Certification:
,4, a1. .q _N Ff! aV, 4,3ag W Via qlayJati
6.Is(are)the well(s): permanent or ❑Temporary Signature f Ce d Well Contractor Date
By signing this form,I hereby certini that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ,Io 15A NCAC 02C.0100 or 15A 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#21 remarks section o on the back of this form. 23.Site diagram or additional well details:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sa:.t: 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
` 'dd'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: yo, (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
10.Static water level below top of casing: 3 QO (ft.) I24a. For All Wells: Original form to Division of Water Resources (DWR),
nformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 (in.) Bit Off: 6.-.9 2D 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Progran 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) `1 Method of test: 'Tie 1 V"'l W-,Z', w
13b.Disinfection type:
70",,,11(H Amount: a3 OZ DATE SITE VISITED: .,2 8'2-3
VISITED BY: .,SAhgc. H scJst,Wd,,4
Department of Environmental Quality-Division of Water Resources 3;6 Li i s, 610 ievised 6-6-2018