GW1--04312_Well Construction - GW1_20240722

WELL O0j' STR_1rJCTI1QN TtE'CQRD('1:W-1) For Internal Use Only:
1.Weti Contractor Informn6on:
rrl WATER ZONES
Well l.e7 FROM To DFsctractor Name r n
�l fL�J ft.
ft. j
NC`�,'-11 Contractor Certification Number 15.OUTER CA
SWG for multi-cased hells ORL7NER if a licable
YADKIN WELL COMPANY,INC. FROM To 7H7CI0• r � 1MIATERIAI.
ft, in.
Company Name O�� �' „„[ _ (�(/Z 5L C>
a"9 rj�7� 16.INNER CASING OR TUBING( eothermil dosed-loop)
2.Wei:Construction Permit#:,- ht4-e• IW X_ d.To I It 31 FROM TO DLkNfETZ S MATERUIL ;
List�•u.roplicoble well construction permiu(i.e.U1C,County,State,Mariance,etc.) ft.
3.Well Use(check well use): ft i °
!'Pater Supply Well: 17.SCREEN
FROM TO DIAMER SLOTSILE T IT MATERIAL
DAgricultural OMunicipaVPublic ft. R• in.
❑Geo:Lcrmal(Hcating/Cooling Supply) DResidential Water Supply(single) ft. in.
DIndit,.zial/Commercial DResidential Water Supply(shared) 18.GROUT
I
DImgation OWells>100,000 GPD FROM TO 1ATERIAL ENITLILCIENrENT hTETI3,PP AMOtINT
NVon=Xzter Supply Well: Q ft.
u^Morstoring ORecovery ft. ft,
Injechoo Well: ft k
DAouifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
CAc,)-.fer Storage and Recovery OSalinity Barrier FROM To nuTERtAL EhYLACEMENTMETHOD
OAquifcr Test OStormwater Drainage ft. ft.
❑Experimental Tecluiology OSubsidence Control ft. tt.
I
OGet:thermal(Closed Loop) OTracet 20.DRILLING LOG attach additional sheets if necessary)
saq ere.
❑Gc_,thcrmtil(Iieating/Cooling RetReturn)Return) :]OtherOther(explain under#21 Remarks) FRO TO DESCR=10Ncolor,hardnev,mil/rock type, ain
ft. k.
S (( ^^ AA
a. :,are`ir'c::(s;Completed:l.1G` 'r WeIIID# /"l�— 11�L It. ot.
w'U v r Gin •x'-1 ft, ft.
Ss. 'e1I Location: Phone # a(�l
Facia!dO«vcr Name ( I Facility ID#(iff applicable) ft, ft. J I I I ) ` 2024
/ U l-t L n 1 we+ � 0'%' k W W� ft. ft. 1 V L v `t
Ph 4dd.css,City,and ZipNc �.�tr10 � � i
ys,cs;. b. , i.. 1 ft'
ft. •�'/�'':i�tav'
_lJ L'i t 'tC 1 �.i 2l.REMARKS
Couc.y Parcel Identification No.(PII]) BORES (C) DEPTH #G-) �_ � siulz C
5b.`.,atitude and longitude in degrees/minutes/seconds or decimal degrees: J LOOPS PER BORE ( C ) DIA OF LOOPS (A
(irwr.11 5eld,one latAougiiiss sufficieot) 0a/� 22.Certification: S D R OF LOOPS ( ! ( )
6.:: are) the well(s): OPermaoent or OTemporary mature oTZcrtifi{!3 Well Contractor Date
By signing this form,]hereby certify that the wells)was(were)constructed in accordcnce with
7.1, this a repair to an existing well: Dyes or ONo I SA NCAC 02C.0100 or 1SA NCAC 01C.0100 Well Construction Standards and ghat o copy
f6 �is a repair,fill out known well construction information and esploin the nature ofihe of this record has been provided to the well owner.
reps under 921 remarks section or on the bock ofthisform.
23,Site diagram or additional well details:
A rear Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this.page to provide additional well construction info
e'nN I G'P 1 is eded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also zir.:.h ar:dit canal pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Land surface: /Gt.1 !t.
Fo,•Tultiple wells lust all depths jdifferent(example-3Q200'and 2©000) ( ) Submit this GW-1 within 30 days of well completion per the following:
10. -static water JcvcJ below top of casing:_ y�0 (ft) 242• For All Wells: Original form to Division of.Water Resources (DWR),
Information Processin
Ijxr:•cr level is above casing,use"+" g Unit,1617 MSC,Raleigh T`iC 27F99_1617
11.7'orchn;e diameter: (in) Bit Off:_C 24b. For Injection Wells: Copy to DWR,Underground-injection Control(IUC)
Program, 1636 MSC,Raleigb,NC 27699-1636.
AIR ROTARY
(ix 'Veil construction dirzbeect
push,
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ix ;user,rotary,cable,duet[push,etc.) county environmenfal health department of the county where installed
FO?1 WATER SUPPL (ELLS ONLY; \ eig24d.For Water Wells producing over 100,000 GPD• Co to D
i3a Yield(gpm)
c Permit Program,I611 MSC,Ralh,NC 27699-161 l
Method of test: Copy CCPCUA
( f�
70%HTH
fo.Disinfection type: Amount: OZ DATE SITE VISITED: Z-
.Pr CE- VISITED BY: PM
Fe: OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018