GW1-2023-00765_Well Construction - GW1_20230112

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I.Well Contractor Information'
14.WATER ZONES
FROM TO DESCRIPTION
Well Contactor Name it
ft
NC Well Contactor CmtilicagaaX—ber 15.OUTER CASING for mulfi-used-vi ells OR LINER Cif ap licable
YADKIN WELL COMPANY,INC. FROM To nrAMLrrER Tffirsavass MATERIAL
ft. ft in.
Company Name ' �3. 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: N %/(� FROM ' To RaLM—TER Tj3acrtNrss MATERIAL
Llsi all applicable well construction permits(i.e.EUC,County, tale,Variance,etc) ; ` ft ft in.
3.Well Use(check well use): ft, ft.
water Su 17,SCREEN
pply Well:
FROM TO DIAMETER SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
LIGeothermal(Heating/Cooling Supply) esidentia]Water Supply(single) ft. ft. in.
❑Industrial/Commercial esidential_\3lBier Supply(shared 18.GROUT
❑hrigation ❑Wells>100,000GPD FROM TO MATERIAL. EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. ft. 8 31,ch;?_5 crt,Vd'Q' 2� �
❑lonitoring ❑Recovery it ft.
Injection Well:
ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO 111ATERLAL -•EmFLACE NT.NMTEOD
❑Aquifer Test ❑Stormwater Drainage ft. ft -
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DFSCR1P',a0 12r -rkty e,E ains6s,etc.
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21Remada)90 f a®d
4.Date Well(s)Completed: a—x-° -XWellID# 1p /6 ' ftft
Sa.Well Location: ne 7 9 d. It
r #7w �
, +. .:f+=:=, :c::_. „•::;;:-;;1 t,;:.;
fL
i s flu S�4<33—jY3 C d� ft o50 fL
'A0 IR®w
Facility/Ova ame FacililyID#(ifapplicable
c-� �tG�c� LI L' Arno y am, ft. ft �' 1, rlt - �c C.fi-tA.
Physical Address,City,and Zip
- C(�/ /1k' Z1.RNMARKR - -
County , Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweD field,one lat/long is sufficient) 22.Certification:
6.Is(are)the weIl(s): Ii3Permanent or ❑Temporary i�Hof Certified Well Contractor Date
By signing thisform,I hereby cerf)�that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or /Io 15ANCAC 02C.0]00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fdl out(mown well construction information and erploin the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks 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 is needed. Indicate TOTAL NUMBER of wells (add'See Oven'in Remarks Box).You may also attach additional pages if necessary. .
drilled: ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - 6 0 a
For multiple wells list all depths Ifdifferent(example-3©200'and2Q100) Submit this GW-1 within 30 days of well completion per the followine..
242. For All Wells: Original form to Division of Water Resources (DWR),
10.Statiewater level below top of casing: Ti (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if-water level is above casing,use'+"
11.Borehole diameter G (in.) Bit Off: 24b.For 11 iection Wells: Copy to DWR,Underground Injection Control(IUC)
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 SUFFLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)
U Method of test: .1d' Permit Program,1611 MSC,Raleigh,NC 27699-I611
•
70%HTH 'M OZ DATE SITE VISITED:
13b.Disinfection type: Amount: .
P_/ISITED BY:
FnrmGw-l_.. ,___ �a1,Quality-T]ivicinnnfWo�o.r7nenu�nne - _ ___ _ _ Revised6_F_9n7v