_Well Construction - GW1_20230315 (58)

. -- L CONSTRUCTION_RECORD (GW-1) For Internal Use Only:
•.,,,
I.Well Contractor Information:
, tea (®®s 14.WATER ZONES
Well Contractor^N�a FROM TO DESCR�rP7,TION
�f�m� /i' ft 1/ .5 ft' ✓4:4 Prar-P(4/
ft, ft
NC Well Contractor Certification Number 15.OUTER CASING(for Multi-cased wells)OR LINER(if applicable) D
YADKIN WELL COMPANY,INC. FROM TO DIAMETER _ TRIMNESS MATERIAL ,
ft. ft. in.
Company Name
�j 16.INNER CASING OR.TUBING(geothermal closed-loop)
2.Well ConstrructionPermit#: ® ($ C9 St Q,y , FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.01C,County,State,Variance,etc) 41 ft , 7/ ft ,6,f)-Tin. Is®iza/ "cc,
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL r�......
❑Agricultural IMunicipal/Public ff. ft. in.
❑Geothermal(Heating/Cooling Supply) ptesidential Water Supply(single) • ft. ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft, et ft, s oat:
ls
OMonitoring ❑Recovery !,7t °ft. Ai
17
Injection Well: ft ff.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ID Other(explain under#21 Remarks) FROM TO DESCRIPTION feeler,hardness,seVrocktype,Rhin size,etc.)
4.Date Well(s)Completed:l '/(0°f-? Well1#A- p 0341' 6"Vft• Pdl-` n1 Ai i9af fr.ey e°544e,
5a-WellLocation: • Phone # %.2Y-Lif 55-)1V' ft ft
ft ft
Facility/OwnerName Facility ITV(if applicable) ft. ft
Physical Address,City,and Zip ft ft
kti®lka 21.REMARKS MAR ? 52.3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '-J' i' •
(if well field,one Iat/longis sufficient) 22.Certification:
3C /'J fro Jq N ri a.5; ,.5QSP W
6.Is(are)'the well(s): Permanent or OTemporary Sign of C • Well Contractor 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 es or l°Qo ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
Phis is a repair,fill out knwn o well construction in ormalion and explain the nature of the of this record has been provided to the well owner.
repair under#2I 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 Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ;4 el''' (ft.
For multiple wells list all depths If-different(example-3@200'and 2©100� ) Submit this GW-1 within 30 days of well completion per the following:
p-•
(
10.Static water level below top of casing: • �+ (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing use"+" //+ 9
11.Borehole diameter: Qv (in.) Bit Off: 6°O 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.WeII 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
13a.Yield(gpm) 470 Method of test: ar°rl Permit Prograrn,1611 MSC,Raleigh,NC 27699-1611. I (�
70%HTH c' OZ DATE SITE VISITED: /1®s `-2' e.'",3-)
13b.Disinfection type: Amount:
�, ,.o. --- VISITED BY: 4/6g ,-.,. iL