_Well Construction - GW1_20230315 (65)

—L CONS TJTJJCT1IQ IIIEC 'D GVV-1Q For Internal UseOnly:
1.Well Contractor Information:
l e(r 14.1WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLI1+iER if a linable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TILICIOVEss MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: lJ �"l� '� FROM TO L>TAI4IETER THICIINE55 A4ATERLAI
Lisr all applicable well construction permits(ie.127C,County,State,Variance,etc) +I ft it et in. sD—( 8'vc r
3,Well Use(check well use): IL ft- in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TIIICIGHESS MATERIAL,
❑Agricultural .[.�IM/unicipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) t4,1dential Water Supply(single) • ft. ft. in.
OIndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>160,000 GPD FROM TO MATERLAL EMPLACEMENT AM,THOD t
OUNT
Non-Water Supply Well: ® it. � ft. Hule Ptv e_ _ 1� 55
❑Monitoring ❑Recovery ft. fL �17 R
�
Injection Well:
ft
❑Aquifer Recharge ❑Groundwater Remediation
19. A
❑Aquifer Storage and Recovery ❑Salinity Banior FR AII�ID/GRTO L PACK MATERIAL EnTPL&CEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. R•
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothumal(Closed Loop) OTracer 20.D71I1,LEiGLOG attach additional iftecessaryl
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Rematics) FROM TO DESCRIPTION e°tor,hxrdaess,soillmrk e,gmin sbx,etc
so,
4.Date Well(s)Completed: Well ID# 9- R 241 it 6n ,
5a.Well Location: Phone #3J(--J-2 g?—,3/q7 ft ft _
ft f- _. ....
Facr7ity/OwnerName Facility M#-(if applicable) ft' ft.
tz
4� �',�! �' � �� it. ft M AR i Lr�.�
Physical Address,City,and zip it it.
` 21.RER2ARKS
County Parcel Identification No.ON)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwell field,one lathongis suiiioient) 22.Certification:
36 0 fqe kk -N 90- ,31/- 2 7
6.Is(are)the well(s): Permanent or ❑Temporary Signature f Certifie Well Contractor Data
By signing thisfarm,thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t0 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 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-b is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarim Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L41 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3Q200'and 2Q7000
�� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5taticwater level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use"+"
11.Borehole diameter: (in.) But Off' L-®,3 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IIIC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(La.auger,rotary,cable,direct push,etc) n�
county environmental health department of the county where installed Vl
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
,,ryry Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �� Method of test: 6-d L� -T t,I-r` '''r
70%HTH q OZ DATE SITE VISITED: r �' C- ,�&43 ly-J
13b.Disinfection type: Amount: F 1 dr_f
Pri cP _
VISITED BY: