GW1--03070_Well Construction - GW1_20230428

T-+J •-,CONST R'1UC l'ON RECORD(GW-F For Internal Use Only:
`i:Well C'9.4reactor Information:
. -`,• Y T 14.WATER ZONES
Well Contractor NamePROM TO _DESCRIPTION
(93 ft. tilt ft. 3' &PP \ GlzAt"
145 CAS ft. ft '
NC Well Contractor Certification Number 15.OUTER CASING multi-cased wells)ORLINER(if ap licable) t�
YADKIN WELL COMPANY,INC. FROM TO 1DL4METERTCNESS MATERIALft. ft in. V) '
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) �r
2.Well Construction Permit#: a?�(/ ./ / PROM TO DIAIo TER THICICN Ss MATERIAL \ J
List all applicable well construction permits(i.e.IBC,County,State,Variance,eta.) 4( loft l!� in. k �1g GQ1 �
) \J
3.Well Use(check well use): ft b R' m. I
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
❑Agricultural ❑Municipal/Public ft. H. in.
❑Geothermal(Heating/Cooling Supply) )residential Water Supply(single) • ft. ft. in. '>-1
. ❑Industrial/Commercial . DResidential Water Supply(shared) iti.GROUT
❑Irrigation ❑Wells>I00,000 GPD FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. . ,1-1,
,7 ft. �. ch1 5 3[ali.1
❑Motutoring DRecovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. I
❑Experimental Technology ❑Subsidence Control ft ft 1
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) �.>�:
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) PROM TO DESCRIPITON(ccmr,hardness,eoDtrvektree,grain size,etc.) „••I
ctqq� ,{AA D ft. Li ft- S Or(©�,.,31:- -crak tdroc _cl
4.Date Well(s)Completed: 3-oiJ 23 Well ID# All e. 33z ft q ft i I j
�6 ft. lV�tx 5 de GticAJ ,I
5a Well Location: Witt!
# y3‘- 95c{-«Fz ft ft �I
av Go j,.Adli Al^etG{itt! seal/ Dea or eb. ilerve. 3
ycj
Facility/Owner Name i Facility ID#(if applicable) f. ft. �^
5 coal e L A v eke/ ft. ft r
( ..l ..(.
� if1..rx
Physical Address,City,and Zip ft ft. n n n ��
`� 21.REMARKS h f f1 G b 111 2')
County�� �` �q k,� Parcel IdentificationNo.(PII) ±nt,rx -"V
( 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �i O C'
72
f (if well field,one let/long is sufficient) 22.Cer' cation:
3� /7/-41,ZG N 7l 3 '. a4t413 w ®. 3 'l; I
, /y 6.Is(are)the well(s): Permanent or ❑Temporary Si atnre of Certifiednfrector Date
By signing thisform,'hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or KID 15ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the ofthis record has been provided to the well owner. f„} 1 I. •
repair under 421 remarks section or on the back of this form. Yt
23.Site diagram or additional well details: A
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 V.+a `^,.,"
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necess:+ ,,.:.:.
drilled: 1 24.SUBMITTAL INSTRUCTIONS ,�\ i',l 11
9.Total well depth below land surface: /CO A (ft.)
For multiple wells list all depths If different(example-3©200'and 2Q1001 Submit this GW-1 within 30 days of well completion per the following: V,
3'� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+" �] f
11.Borehole diameter j (in,) Bit Off: t°125 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
I-f Permit Program,1611 MSC,Raleigh,NC 27699-1611 f k l tip
13a.Yield(gpm) [ Method of test: G$61Y 1 p
13b.Disinfection type:
70%NTH
• Amount: 19 OZ DATE SITE VISITED: lU l-.2 2-
%? (, er
t�- G
VISITFD RY: ��A ` (10 l+, 12,61