_Well Construction - GW1_20230315 (57)

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..'b%ITii 1 ONS TRTJCTION RECORD tCO1 (GW ) For Internal Use Only:
1.Well Contractor Information: .
w7e rr' Wa+`�► to$ 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name
ft. pen, ft. is- GPD
,Li S a BQ ft. Q s° ft LIS G Pen
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name i l 1...(0) $%.(. ( -�-/'7//���30 16.Th1NER CASING OR TURING(geothermal dosed-loop
2.Well Construction Permit#: ( /(30 FROM TO DIAMETER THICIINESS MATERIAL
List all applicable well construction permits i.e.fIIC,County,Slate,Variance,etc.) +I ft to ft I/_ 1/q tu• SDR a% P u e
3.Well Use(check well use): ft ft. [J in•
Water Supply Well: 17.SCREEN
FROM TO DIA.METER. SLOT SIZE THIC1OIESS MATERIAL
❑Agricultural ❑MMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Ill esidential Water Supply(single) • ft. ft. in.
❑Indust ial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑krigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: 0 ft. 2 y f- golf PIS poureJ IS bg55,
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft• ft•
DExperimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ,
FROM TO DESCRIPTION(ruler,hardness,soil/roektype,grain sae,etc.)
❑Geothermal(Heating/CoolingReiman) ❑Other(explain under 421Remarics)
/� T� C7 ft /0Q ft . 5a 1 I
4.Date Well(s)Completed: ?113 L 3 WellID# 49- C7 b✓ too 3®, ft 6e o
' 5a.WellLocation: Phone # -' g:-. ?L...?--11 y3
j P ft ft
Facility/Own Name Facility#(if applicable) ft ft -.:.
i ft. ft. C
'#11 T Crate (_., • . _ . (,4A0 .7
Physical Address,City,and Zip ft ft.
),(ki f Jr -. 21.REMARKS
County Parcel Identification No.(PIN) Q
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
3(J ix-.. tic, N -...5-5:- 0 W 2113\23
6.Is are the wells: @lsermanent or ❑Tem oary Sign�e of C ed Well Contractor Date
Ls(are) O P
��� By signing this form,I hereby cerl�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Ill A. 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis tea repair,fill out known well construction information and explain the nature of the. of this record has been provided to the well owner.
repair wider#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 GVT-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
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 Ifdifferent(example-3(n 200'and 2Q100')
6 O (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 9..
If water level is above casing,use"+"
) Bit Off: 5.9�, 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) V
11.Borehole diameter: �O (in 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
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed V
FOR WATER SUPPLY WETS S ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA/ V
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Lao Method of test: A:or
e DATE SITE VISITED: /0- - 2 2
13b.Disinfection type: 70/o HTH Amount: ` I OZ 3