GW1-2023-00721_Well Construction - GW1_20230113

NS For Internal Use Only:
1.Well Contractor Information: -
©�� 14.WATER ZONES
PROM TO DESCRII'T10N
Well contractor Nam
c3-s-7-a-A y ft.
ft. it
NC Well Contractor Certification Number 15.OUTER CASING for multi-casul wells OR LINER if applicab
YADKIN WELL COMPANY,INC. FROM To DLIMETEB. AL THICKNESS MATERI �
fr. ft. in. �.
Company Name S4 3
16.IlVNER CASING OR TUBING eo•therma]closed-loop)
2.Well Construction Permit#: P P W L ZO 2 2 O 2.CLS Y FROM TO DIAMEITF; THICI4PESs MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) I It
7q it �.� iu { ' V L
3.Well Use(check well use): ft fr. in. LA
Wa r Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TEaCIOVESS MATERIAL
XXcultnral ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) BBosidential Water Supply(single) ft, ft, Ir.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft. to .ti o-V y n,
❑Monitoring ❑Recovery it . fr. A u/ 'J ell-
Injection Well: -
it ft.
[]Aquifer Recharge ❑Groundwater Remediation -
19.SANDIGRAVEL PACK(If 211VIJ ca'Sle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Eh LACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additions]sheets if necessary)
FROM TO DESCRIPTION color,hnrdnus,soiVrock c, rain sae,etc.
❑Geothermal(HeatinglCooimg Rctum) ❑Other(explain under#21 Remarks) O ft ft. ©.
ft. ft
4.Date Wells Completed: a' 3- Well ID# /0 S /'YII°6 B d e•
O p / (c �
5a.Well Location: Phone #33G- `7 93-72y ft 3 ft orb `r ;.e trio- e
Facility/Owner Name FacilityIIM#(if applicable) ft ft
fL ft
Physical Address,city,and lip ft ft.
21.REMARKS -
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lat/longis sufficient) 22.Certification:
3C " ZY. 7 3a N OC401` 27 5' (14 W
6.Is(are)the well(s): Ifffermanent or ❑Temporary
5' re of ed Wcll� Date
� By signing thisfarm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I`4 ISANCAC 02C.0100 or ISA NCAC 02(:.0200 Well Construction Standards and that a copy
Ifihir is a repair,fill out 10own well construction information and explain the nature of the of this record has been provided to the wall owner.
repair under it21 remarkr section or on the back of this form.
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 needed, Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box). You may also attach additional pages ifnecessary.
drilled: f 24.SUBNIITTAL INSTRUCTIiX_NS
9.Total well depth below land surface: d�d- (ft.) I
For multiple wells list all depths(different(example-3(a)200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water Ievel below top of casing: so (ft.) 24a. For All Wells: Original Jorm to Division of Water Resources (DWR),
Ifwaier level is above casing,use"+" p Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 4
11.Borehole diameter (in.) Bit Off: �. /e�S� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigb,NC 2,7699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Opr:n-Loop Geothermal Return Wells:Copy to the aj
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPT v WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
AA ( Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) � �a _ Method oftest: /7�/ o'1iDrf� 5& "J P�•
fe 70%HTH /,,r Oz DATE SITE VISITED: /- 2-7-
SIB rr. t}, '
13b.Disinction type: Amount: ��-
s
VISITED BY: b 4-ah-e `-T 1
t er ofE�onmental Oualitv-Division of Water Resources Rev sad"-7nf R