GW1--03109_Well Construction - GW1_20230428

5
r-WELlt.,gQbN5 TRUCT11QN RIECORD � �i�l-'1'd For Internal Use Only:
1.Well Contractor information: LL
_ C«1 L�a+FteAS 14.WATER ZONES
FROM TO DESCRIPTION
well Contractor Name ft, oil ft. I
614 TP A o mw
ft. 2 7v it. & G Pv�%
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells)ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THIt�OVEss MATERLIL
ft ft in.
Company Name 16.RTM CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: .s n s- FROM TO DIAMETER THIcltivEss MATERIAL
List all applicable well construction permits(,e.LUC,County,State,Variance,etc) .I ft• l ft. S in. ` ,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: F1tOM Lr O DIAMETER SLOT SIZE TB clac"SS MATERIAL
❑Agricultural ❑Iv�lunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!1dsidential Water Supply(single) ft. ft. in.
OIndustrial/Commercial OResidential Water Supply(shared) 1O.GROUT
[Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. ♦_ ft. 1661e 101 duradt gS
❑Monitoring ❑Recovery it alck 6t.
Injection Well: �t7
ft ft.
❑Aquifer Recharge ❑Grolmdwater Remediation
19.SAND/GRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPL.ACENMNTMETHOD J
❑Aquifer Test ❑Stormwater Drainage ft. ft.
[Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(CIosed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/CooEngReturn) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,snii1mck •a six ete
tt�� O ft ft 5011
4.Date Well(s)Completed: .3 D3 Well�ID# 9r'.. ft � `ra A a
�� e�a -h.^4L rKc ON5a.Well Location: r) Phone -r®R- 3`72�
ft. ft
�:d��y S a aev ( racHl.r sap 7oq�- 3 D-vi
Facility/Owner Name Facility ID#(if applicable) ft ft ("; �+ s, (i-w-i i
Physical Address,City,and Zip ft ft
V-3�z'/ 21.REMARKS v
P'' 1 ifii=Sit L`,t r- I:,i fit
County - r Parcel Identification No.(MD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
6.Is(are)the welI(s): 4ermanent or ❑Temporary Signaturl of CerVed Well Contractor Date
Bysigningthisform,l hereby cert#y that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well., ❑Yes or QNfo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fdl out known well construction information and explain the nature ofthe of this record has been provided io the well owner.
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
B.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 -I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 G2 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3©200'and 2Q100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 40 (fti) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+'
11.Borehole diameter (in.) Bit Off: S.99 G 74b.For Irtiection Wells: Copy to DWR,Underground Injection Control(IUC)
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
(Le.auger,rotary,cable,direct pusb,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA f,
/� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: /•��� � �
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
��VISITED BY: