GW1-2023-02188_Well Construction - GW1_20230306

WELL`1L CO,NS'ne.UCTI'ON_RECORD D (GW- .) For Internal Use Only:
11.Well Contractor Information:
Cbt.1-5 f .�-e V-el U3 .• 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
® -- A 2 cl D ft. 61 s f`' i p vt-rk
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL \ /
Company Name ft. e, ft I g in. 5 l� -�" r �lU
16.INNER CASING OR TUBING(geothermal dosed-loop) '
2.Well Construction Permit#: IA)p . 6/® 3 a PROM TO _DIAMETER THICKNESS MATERIAL
List all applicable well construclionpermits(i.e.UIC,County,Slate,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DM icipal/Pnblic ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) • ft ft. in.
❑Industrial/Commercial . DResidential Water Supply(shared) 18.GROUT Si
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C.) ft 9,' ft. t�64011ff (hp l f,J�k ,i,.., p/At-�'.... ;
❑Monitoring DRecovery ._ ---- .-. - .- -:�--, ft. ft.
Injection Well: 1, , `-i <. ' ;-; '.-,
❑Aquifer Recharge ❑Groundwater Remediaiion c 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier MAR 0 :3 Z@ 1 t FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage•. .;, _,- i I;,i ft. ft'
ni•'
❑Experimental Technology ❑SubsiBenceCoii$of `J,`o�---.;G ft. ft. 6.4
N/ ❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
C ❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM R TO fL DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
((�736,-/a pp �j.�, i S S4.: I a- Lo®u 5 p- --
id 4.Date Well(s)Completechr-1/ ?weIIID# � 2- °' lc R' 9. R' n®C k 1- n1,,• 1„�i a( �cv if t
t. t�'Ides (ra.y,,, pc,0la .- �-- ft 311 �' � ��' l�y��
la 5a.Well Location: Phone# 3%r W()9-4.7 kx A //�°°a r✓x_s:.Lv/.�
ft. G� ft c� t"sro+i K G 'f 14�
Faajility/OwnerName/l Facil�ifpyID#1(.ifaapplicable) I ft' �� ft. It �t -4. Y 5.,
t� l�°-7 Oil 1(D". ItoG�JIr)1'�-IL 00- ft. ga3 ft FL (( a II
' Physical Address,City,and Zip ft. R. •
Dctv b 21.REMARKS ], I l
County Parcel Identification No.(PIN) i u'i' i? SC O•� p i�t e s `r®t l'1®f"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: +l%-C_ f`. �" r.
(if well field,one lat/Iongis sufficient) 22.Certifi,ation:
psi' So 110 3 N (.3'') ZS'• de®3
'' i I°,L_ __y_l_pLL13
6.Is(are)the well(s): OPermanent or '❑Temporary !•e of Certified Well Contractor Date
�� - :•signing thisform,'hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or q�tVo 15A NCAC 02C.0100 or UA NC4C 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 under1121 remarks section or on the back ofthisform. 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 Remarlca Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: f° 3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3(a 200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
ID.Sfaticwaterlevel below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 6 (in.) Bit Off: �'03...5 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.WeIl construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta.) 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 k
pp A.ty. P i __/( Permit Program,1611 MSC,Raleigh,NC 27699-1611 J
13a.Yield(gpm) l Method of test: �"' ,\' t
70%HTH 3 3 oz DATE SITE VISITED: 1 1-1-2-2 \`'
13b.Disinfection type: Amount: �'
VISITED BY: ®, a1ti�1'�2 Pri r'__ -