GW1--03079_Well Construction - GW1_20230428

3t,T613 'ONS TR'TJCTLON RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ,
crY cAlcki-lc/! 14.WATER ZONES
FROM TO DESCRIPTION (O
Wr,il Contractor/Name
d�rr ./9 b
J�I`I ft.. 00 fr' 2t Fin ..�
NC Well Contractor Certification Number �it 4 ca Gera
15,OUTER CASING(forniulti-rased wells)OR LINER(if ap livable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
_A': t..,-/4-Company Name 16.IN NER CASIPG OR.TUBING(geothermal closed-loop)
2.Well Construction Permit#: PRWI. zo2 a 0 c1 Pc FROM TO _DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,eta) t r ft I I i ft G`le in. , ' 88 GAL/
ft R
3.Well Use(check well use): ' in.
Water Supply Well: I7'SCREEN
FROM TO DIAMETER SLOT SIZE TmC1a Ess MATERIAL
❑Agricultural CMunicipal/Public '
❑Geothermal(Heating/Cooling Supply) !esidential Water Supply(single) • it. .
/ 7
ZZr
❑IndushiallConunercial - DResidential Water Supply(shared) g•GROUT
❑lsrigation ❑Wells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: Q ft. s ft Nate Pto5 Pe uee-d
OMonitoring ❑Recovery it ft. 31 `
Injection Well: S 73 �(.7' nci:66e0k Puw S l bps
ft ft
DAquifer Recharge ❑Groundwater Remediation _
19.SAND/GRAVEL PACK(f applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Storrnwater Drainage ft, ft f;
❑Experimental Technology ❑Subsidence Control d - ®f{ / -,,V -,/"...
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Mar,hardness,sot/reek typo grain size,etc.)
/�p� '` o Jos ft 601 I
4.Date Well(s)Completed: 3` I 1`D3 C�[ ID#A1s1"'�ZT' l os ft 302 ft G(,at -1r t a R y
5a.Well Location: Phone #.331f4' rr ft.ex '" , ' , .�'1 .�
• Iyel C + s�C.r.IIieem tilei1 j 4J. 6't'`33C'.�2tt•9J r it ft ram! n 2 (' 2023
Facility/OwnerName Facility ID#(if applicable) ft. ft.
!�A g� p� ft. ft 10ortr,-s �n Pi.^::�iri.:r'7 Lim:
ft ft
Physical Address,City,and Zip
�� to.)," 21.RRMARKS
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:
3(c' (9. 7,32- N 57 2 r/ SY5/ W w 3 i ;3
6.Is(are)the well(s): t�i'ermanent or ❑Temporary Signature f Certifi Well Contractor 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 Al<1 ISA NCAC 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 explain the nature of the of this record has been provided to the well owner.
repair under ii21 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 G-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 a (ft-) Submit this GW-1 within 30 days of well completion per the following: \��N
For multiple wells list all depths If different(example-3©200'and 2(4100')
JO ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
ID.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
(in.) Bit Off: 4.022 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) et
II.Borehole diam eter: Program,1636 MSC,Raleigh,NC 27699-1636
I r AIR ROTARY VoJ�
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to thd\
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 43`
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
S O APermit Program,1611 MSC,Raleigh,NC 27699-1611 5 ,Ar.
13a.Yield(gpm) Method of test: (A q.
I sc...b .g t.3nCra`
t,.. � .'r
70%HTH 13 OZ DATE SITE VISITED:/i'a l -Z.Z.13b.Disinfection type: Amount
,may ba d) 9k (
Uri rya. In
VISITED BY: o
, K(,L Ili Cr....