GW1--03064_Well Construction - GW1_20230428

WELL,L'ONSTRUCTTON rCORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �
eEj r--i ' 9 1 �3"i) TBi-i 05 14.WATER PONES 1
Well Contractor Name 1 _FROM TO DESCRIPTION
i . . DLLs 0A ft, ft
1W Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable)
YADKIN WELL COMPANY,INC. • FROM TO -DIAMETER , THICKNESS MATERIAL
ft. ft. in.
Company Name -
�( 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: O®L) 7 FROM _ TO _DIAMETER , THICKNESS _ MATERIAL
List all applicable well construction permits(Lc.UIC,County,State,Variance,etc.) 4.' ft. eia ft b S[�� °1 in. 6 6% 6 J p v
3.Well Use(check well use): if., ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI1.E THICKNESS MATERIAL _
❑Agricultural DMunicipal/Public ft• ft. in
OGeothermal(Heating/Cooling Supply) r9sidential Water Supply(single) • ft. ft. in:' ,
[Industrial/Commercial . OResidential Water Supply(shared) 16.GROUT
❑IIrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: ® ft. g ftiPidePio5 , Pour, ) 3 VV
OMonitoring ❑Recovery Ilf it J.r ,ft- 4iad 6re..ai Po►tro 3
Injection Well: '
S. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMFLACEMENTMETHOD
•
OAquifer Test 0Storrnwater Drainage ft ft`
❑Experimental Technology ❑Subsidence Control it ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness.soillrncktype,grain sue etc.)
J f g� C9 ft gS ft.
501/
4.Date Well(s)Completed: '113 1 )3 Well ID# ARP 9-� es- ft. s-e2. R 6ca„rash
5a.Well Location: _ Phone # qic; ® E iq-'2r
ft. ft. .- �.'Y'tom'
• e� � ��� r -- '' s��,-,•
Facility/OwnerName FacilitylD#(if applicable) ft' `�`�` "�'i�L„;
i366'2- Ilk., f/Z ,j ntuitz44 cruLex.mc ft. APk 2 8 (n23
Physical Address,City,and Zip 8 ft. ft Inca rt;t;a .,,,,,..
`�' 4-�9`l .A - 21,RF.MARTtC C1Ps .l �lJr
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3C 4 F137. N g, ZOr Z-12- w 23
6.Is(are)the well(s): CBYermanent or OTemporary 5ignatn a of Ce ed Well Contractor Date '
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or glfVo 15A NCf4C 02C.0100 or I5A NCAC D2C.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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same is needed. Indicate TOTAL NUMBER of wells
construction,only 1 GW-1 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
,
drilled: .( 1A.SUBIV11TTAL INSTRUCTIONS
9.Total well depth below land surface: 82 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Iist all depths If dijPrent(example-3@200'and 2©1000'
D®® (ft) 24a(For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
(i) Bit Off: 0ek 24h•For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: 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
(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 _t
ay,1 dA 1`• Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) �f! Method of test: 1
Q e,
70%HTHig OZ DATE SITE VISITED: /®-) �'- 2_Ti c�3 a,
13b.Disinfection type: Amount: ____ r
-- - i VISITED BY: O' t9.99 .
Pri rir
r__.:_„i nrorimental ni,mra.-T...;.......,.rnr.,.e.17 oentwnar Basic.a 4_6_7111 a