GW1-2023-02189_Well Construction - GW1_20230306

k; ',CONSTRUCTION RECORD(GW-i) For Internal Use Only:
1.Well Contractor Information:
if;�L�S 3 .Q l/ 1 14.WATER ZONES
TO
Well Contractor Name Mum - DESCRIPTION
2 D3 5( - A IL; ft. lop ft. 104.0.4- (ley-ivt,K t.'(--L
NC Well Contractor Certification Number 13 5 ft. 7 tic." ! . ` .5 6- r' t,15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM To _DIAMETER TEICKNESS jMJATERIAL
Company Name 'iJ�d, 3JC 7,�-3� 61�'� w
T ft. 0 ft6i12$ . 5DR 9P f"v C
16.INNER CASING OR TURING(geothermal closed-loop
2.Well Construction Permit#: '7 ()A cii' FROM , TO DIAMETER THICKNESS MATERIAL
alb
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft. ft. iu.
3.Well Use(check well use): ft ft, in.
17.SCREEN
Water Supply Well:
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M3,icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) e6sidential Water Supply(single) • ft. ft, in.
❑Industrial/Commercial - ❑Residential Water Supply(shared) IB.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT •
Non-Water Supply Well: 0 ft. 9 9l e( ft. /3et,Rvbistc. '� 14ydK L i'v pr&cam.. .
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwatek Reme'diatiod' "•"-_.
19.SAID/GRAVEL.PACK(if applicable)
❑Aquifer Storage and Recovery El Salinity Barrie T •.0Z3 FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑StormwateM1r i tage.J ft. ft
i�
❑Experimental Technology DSubsidence_Co4trpl'r:.: : ::.3 '=, ft. ft.
❑Geothermal(Closed Loop) OTraeer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(molar,hardness,eoWroektype grain ek eta)
VI 3a� 0 ft. 10 ft. S�� ��I/®e�� s��-
4.Date Well(s)Completed:D / �iJ c�3,WeIIID# ft' f 6;.a.g,� �(,.`. cse_k
5a.Well Location: Phone #:".. - 3 1/- `7317 IS ft S 5 ft I- e°'3 ile i-4 Aet1.✓-a-42 64"'`Y
• F-IeNan'{c.trr cr Ltirvi SS f• 1l( f. , /Gay 1 �
Facility/Owner Name Facility DV(if applicable) ')tiff. %l Q.ft. I( 1 l I c
1 g1 1t,«-��f n-. 44marlC- 'J,�9?" ?aAft ' I1 it 01 J/'/ ,,� ....CP'
Physical Address,City,and Zip
21.REMARKS
County Parcel Parcel Identification No.(PIN) I Cr.V d SiGaviaC� 14-A.t.'e- i" 's-.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Swell field,one lat/longis sufficient) 22.Certifie:lion:
.3 LC'. l"S (3 CI N 8.404 2-s: 9 q q (:.2<9 .eL 49,(re6rjj/ge
6.Is(are)the well(s): manent or ❑Temporary ign.,. of Certified W4,)
itractor Date
By signing thisfarm,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or M 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under i21 remarks section or on the back of thisform.
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 Remarlo Box).You may also attach additional pages if necessary.
drilled: 24.SUBMLTTALINSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(example-3©200'and 2©I00)
( ) 24a. For All Wells: Original form to Division of Water Resources (DWR), it
10.Static
level below top of easing: G?t� ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater levell Is Is above casing,use"+
1n�S Bit Off: 6,6Yg' 24b.For Injection Wells: Copy to DWR,Underground Injection Control gip
11.Borehole diameter: Co (�•) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY a
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WET.LS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
�, _ J� Permit Program, MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) ` b S Method of test: llr (-4 0 1'4,1,,.,,,
e OZ DATE SITE VISITED: ep®7 - X-t
13b.Disinfection type: 70/o HTH Amount: 6
T__ _^ VISITED BY: EX3