GW1-2023-01829_Well Construction - GW1_20230223

W.U CONSTRUCTION RECORD (Gib-1) For Internal Use Only:
Well Contractor Information: n
Cce�_ 14.WATERZONES
PROM To DESCRIPTION
Well Contractor N a _�+e -�1
1
9 5-7 -a ft. ft.
NC Well Contractor Certification Number 15.OUTER
PROM CT G for mulUI�TER bl
D R lMTeE AL
YADKIN WEL COMPANY,INC. TLN
ft. ft. in.
Company Name /� �s 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#:A J.S M � �o /�' e-0 i Z FROMI TO DIAMETER TBICI(NESS MATERIAL
List all applicable well construction pumits(i.e.MC,County,Slate,Variance,etc.) ft. tt. / S- In.
3.Well Use(check well use): ft. ft. �e in. �M r
Water Supply Well: 17.SCREEN
PROM TO I DIAMETER J SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fr. in.
❑Gcothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMLACEMBNTMETHOD&AMODNT
Non-Water Supply Well: 0 ft. a fr. 00"l-ett.l. Irew
❑Monitoring ❑Recovery ft. ft. r"-flve't/
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a linable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEtVIIiNrMEI'HOD
❑Aquifer Test ❑Stonnwater Drainage ft. fL '
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheet:if necessary)
❑Geothermal(Heating/Cooling Return) ❑Cther(explain Under#21 Remarlo) FROM TO DESCRIPTION color,hardness,son/rock 4 is sae,etc
4.Date Well(s)Completed: Well ID# 3 7 'ft 07 fr. i'J'1 Xb - fZ PLs^
5a.Well Location: ft.
Phone #3.X�J'3oP �202
r ft. ft.
Uu a ese, G C1 I,a W
Facilityl6wner Name Facility IDN(if applicable) fL ft
fL
Physical Address,City,and Zip ft ft
21.REMARKS
ldd ►�
County Parcel Wentificatim No.MN)
t!r-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
13 . O! N W �-9/ PIS 1 W /7-
6.h(are)the well(s): W24manent or ❑Temporary Sign of CertWed Well Contractor Date
��( By signing thisform,l hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an Wsting well: ❑Yes or &.(0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy i
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#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 GVj(-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface:' (ft) Submit this GWA within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(ex=ple-3@200'and2t@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7 S (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaier level is above casing,use"+"
Bit Off: ,d[-7
S_ 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: C. _(in.) Program,1636 MSC,Raleigh,NC 27699-1636 t
12.Well construction method: AIR ROTARY 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
O Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: . `
o DATE SITE VISITED: [' 2 3
13b.Disinfection type: 70/o HTH Amount: OZ may/
VISITED BY: D
P r i r-P -
,,,e W Quality-Division of Water Resources Revised 6-6-2018