GW1--03076_Well Construction - GW1_20230428

'S) C O NS'1JKUCTION ,CO (GW-1) For Internal Use Only:
I.Well Contractor Information: I r
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N t ( i. G`fl _ C V.6 14.WATER ZONES I -�.
Well Contractor Name FROM TO DSESSCRIPTION
?.-/ j 1 Oil ft. / /S- ft. .DESCRIPTION
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NC Well Contractor Certification Number...3 6 - 1'a`r ft e �� f t s6��e�
15.OUTER CASING(far multi-cased wells)OR RLINER(If ap linable) iik
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name I t
�J 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: PP(�.V L 2.O Z (: / 3 9-r FROM TO DIAMETER. THICKNESS MATERIALIlb ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) +HI- ft a.Li ft /S p �T t��(n. D/1 p (ov
3.Well Use(check well use): ft. ft. �+ in.
Water,Supply Well: FROMCREEN TO DIAMETER SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public t t, �o. :.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial - ❑Residential Water Supply(shared) i
113.GROUT
❑Irrigation .,..E ells>100,000 GPD PROM TO tMATERAAL. EMPLACEMENT METHOD&AMOUNT i
Non-Water Supply','4�r17x�► \a 0 ". 4 f- tso-i;'a hill a�`'G al,•'r+� J e ti(-1.0r ei 1
DMonitoring ❑Recovery ft. ft l"� ��+`A
Injection Well: AR 2 S LU -i ft ft lir
❑Aquifer Recharge ❑GrpundwaterRemediation b)
.c&Z-V. g rvA 19.SAND/GRAVEL PACK(if applicable)
[Aquifer Storagugdyl e '�y L, ❑Salmlty Barrier FROM TO MATERIAL EINIPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft. ,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRIPTION(cnloa hardness,so;vror3crypq grain size,oft-)
�f /� 'A 0 ft 2_ ft ,f la i i/
4. ate FVPell(s)Completed
- ell UV l'3°® tf 26 1 ft. 1 ft. (3,! ,L,,l ("`if,, - PO
�aS �° Bart 6 ece�S.v.-0:03 'q � Lt,_ ft .-e i I
5a.Well Location: Phone 33'6, ii.I.3-12-9
/ 1aPef®F/® -4- Gave Y 4�ft 10Lt ft oSe'CT c•/re:J ,-4(1.a/te�F 1
Il J d J r �'
Facility/OwnerName FacilityID#(if applicable) 1 r/I.t ft Pft ,�;loee61 so��, �et� �e �,1+ �e �,/
Gut &A� al . r?.. iN ft. ft.
Physmal Address,City,and Zip a I/,j ft -1,• ft 9/G2,kJ-.
7'dR P-Z 'cc ( •
21.REMARKS
EA.►,t/y'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'Ito •
(if well field,one lat/long is sufficient) 22.Certification: �
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44)
6.Is(are)the well(s):,.QPermanent or ❑Temporary SignatnreofCertifiedWellContractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under 1121 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlm Box).You may also attach additional pages ifnecessary.
drilled: ( 24.SUBMITTAL INSTRUCTIONS E
atil-
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 IIfdii ferent(example-3(a)200'and 2©100')
6 V 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" t� �a
_ ii.Borehole diameter: G (in.) Bit Off: • n ',p/ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Y r 14% 11 Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
o 11 (ie.auge,rotary,cable,direct push,etc.) county environmental health department of the county where installed
N.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR, UA
5 ' Permit Program,1611 MSC,Raleigh,NC 27699-1611 �
13a.Yield(gpm) �'' - Method of test: ��I V,/
70a/o HTH p�) OZ DATE SITE VISITED: i 1'.3` 2-1- \\ \��
13b.Disinfection type: Amount: �.I.. 0\
q?
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Pr re..:1 _ VISITED BY: D