_Well Construction - GW1_20230315 (60)

` leFE1 LL',CONSTR'UC1TI'ON RECORD (GW-1) For Internal Use Only:
.
I.Well Contractor Information:
COC) 1 14.WATER ZONES D
FROM TO DESCRIPTION
Well Contractor Name
6 17t-ft. 17q- ft. 'A �i t'l C kw"I 1q ft. 32a7 ft 10o GPM 1.,Wt45 Cc' i�$'Crtfr z.tvic,,
NO Well Contactor Certification Number 15.OUTER CASING•(for multi-cased wells)OR LINER(if ap licable) \
YADKIN WELL COMPANY,INC, v FROM TO _DIAMETER THICFO1Ess MATERIAL
ft. ft in.
Company Name ;a�(� 3 -clir e, p7 Q.D 16.DINER CASING OR T[ISING(geothermal closed-loop)
2.Well Construction Permit#: CI •�W 6 FROM TO _DIAMETER THICIINESS MATERIAL
u � ia Z- +1 ft 9 ft ��.` ID. Le 1 r C List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) � `i � !�1���;.�,)
3.Well Use(check well use): ft ft. in. pp
17.SCREEN 4-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in. r n
['Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) • ft ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>I00,000 GPD FROM TO MATERIAL EM7PLACEMitNTMfETH D&AMOUNT
Non-Water Supply Well: ft. �ix ft. Tim a; 9 v y k �co
DMonitoring [Recovery ft. ft.
Injection Well: ft ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM PI ACEMENT METHOD
DAquifer Test ❑Stonnwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. it
DGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,saillroeh type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#121Remadcs) O 1-1Zft `
4.Date Well(s)Completed: ell DV PAR- 3b1s 4), ft. So ft• 5G`r-} c.,,AN1it. O1a1T°C/ ire..r
Sa,Well Location: Phone#7 3,e 43`7-0G 2.4, I-SC) it `CC)ft. /401"In I'vA ektni'11e tV
R ttn* 4-'S i®e II R y.c1 '4ker eft 3911 ft Safi- (ri i51 Safi 03
Facility/0 Facility DV(if applicable) ft ft.
2(Q r Roo &�� 1,.-i. TovNej(r/itt-,
Physical�l Address,City,and Zipft . .:vl�„ 1 i f -1
7 Q t� i t^ 21.REMARKS i\ I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,on:lat/longis sufficient) 22.Certification:
3C° 13. N g0'' Y-5(, I q w Ga y • d --,X•-,2,.
6.Is(are)the well(s): 19Permanent or ❑Temporary gnatureofC ontractor Date
�� By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well' DYes or Colo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out]mown well construction nlormation and explain the nature of the of this 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 Over'in RemarIG Box).You may also attars additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
t"J
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 Iist all depths IIfdifferent(example-3@200'and 2@100')
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
Ifwater level is above casing,use"+" � -
11.Borehole diameter: �j (in.) Bit Off: Iittet.X.,0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) Q
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 C
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
,./ Permit Program,1611 MSC,Raleigh,NC 27699-1611
P
13a.Yield(gpm) I Method of test: /t1`. Cy •6..,.,i r(y„....,4._
c DATE SITE VISITED: l 2 1- INN..r,v 0�+,,•1-
13b.Disinfection type: 70/c HTH OZ lb c'. `-Amount: i6
( -
' - - VISITED BY: h .]0