GW1-2023-01787_Well Construction - GW1_20230223

LL CONSTRUCTION RE ODRD (GW-1) For Internal Use Only:
1.Well Contractor Informnt;on:
Cyv�t�� rD 14.WATER ZONES
FROM TO DESCRIPTION
6 Ant
Well Contractor Nam
[� ft. CSC ft-
'KC 1
Well Contractor Certification Number 15.OUTER CASING for multi-rased wells)OR LINER if a I;rabI
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING rothermal closed-loop)
2.Well Construction Permit#: f/+blft. FROM TO DIAMETER THICIMSS MATERIAL,
List all applicable well construction permits r,e,b7 ,County,Slate,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft• ft. in.
17.SCREEN
Water Supply Well: L71Ohl TO DIAMETER sLOTSL'E THICKNESS MATERIAL
❑Agricultura] ❑M icipal/Public ft• ft. in. 1
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) - ft ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) ig.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft �'C' , ` /
' t X
❑Monitoring ❑Recovery ft ft.
Injection Well: ft ft —
[]Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery El Barrier i g ) FROM
SAND/GRAVEL PACK(-rf a licable)
q �3 L FROM TO MATER]A_L E]V�LACEMLNT METHOD
❑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 DESCRI?TION color,hardness,sot]/-Ck 4 a;n sue,etc
El Geothermal(Heating/CoolmgReturn) ❑Other(explain under#21 Remarks) ^
� 6 ft. dV ft. 4 A V r—y s s�.. '/ ,� of
4.Date Well(s)Completed:��/�1�+" L J Well ID# I ft. I ft. C9e e►
-ter a�` �-� !� t �s .•,b�..r� � ,..�
Spa Well Location: �PhOrie # SA- �!— 1-7-7& ft ( ft L.a<<��.3 �a/,�A�%:f.M' �!•�/� �t��l
hY®X `� A r 4eon 6°J lk-d ie . , ft. ft l ej qJ
Facility/ wnerName Facdity ID#(if applicable) "• ft•
�V /���r�, �� k Q.� ���,��,, c poi ft. --
I It u b
Physical Address,City,and Zip
ft. ft
fall V r 21.REMARKS pp
County f Parcel Identification No.(PIN) St t ,t'F q,,.r Y' L'1♦` ::1 i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,on/e latliong is:a$"icient) ;22Ce-,r1fi1f4x *on:
0
6.Is(are)the well(s): Permanent or ❑Temporary f Certified Well Contractor Date
- hisform,I hereby cert;fy that the wells)war(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or �O ISA NCAC 02C.0100 or I5A 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 afthe of this record has been provided to the Hell 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
1�,/ , 24.SUBMITTAL INSTRUCU0114S
9.Total tvell depth below land surface: r�L- ^ A)
V
For multiple wells list all depths ifdifferent(example-3 c©200'and 2@1000 Submit this GWA within 30 days of'well completion per the following:
5 ( ) 242. For All Wells: Original form to Division of Water Resources (DWR),
IJwater level/s above casing,f Static water levelcasing,use "+"below top of casing:_ �- ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 6,N& 24b. For Injection 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 SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA Q
f 1/ 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611 I
132.Yield(gpm) Method oftest: +r u CA1t✓.x41 y 1',,,t,l..
13b.Disinfection type: 70%HTH Amount: 311
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DATE SITE VISITED_ [—2-cl" �`,LJ t i') nt✓�
,-,_•, „� _ -- -- VISITED BY: (,) I � PwK