GW1--03113_Well Construction - GW1_20230428

WELL'.CONSTRUCTION RECORD' (GWV-1) r For Internal Use Only:
1.Well Contractor Information:
, .6 \ I
C■el 10` A 9 S 19.WATER ZONESCI;
FROM TO DESCRIPTION
Well Contractor N azanantlll e ' maP
.g ft. ,,)I4e/ffi f/ �y Gs''%
6i �' 7a 'I /0 ft. ft 9S3,..... qyr,---011
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased wells!! RLINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM 1 TO r DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3 7�® g� r ft. ft. 1)-5- in. �9 � -> -
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) •I,+'` • 7/ t��>> PE.S.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICtavESS MAT
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ff1,14idential Water Supply(single) ft. ft. in.
❑Industrial/Cornmercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. et ft. # th r.j ?' d e/T
❑Monitoring DRecovery O'' ft. j ft flea) tni pa' /y15 #
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sm7/rocktype,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ey ft. t <,/
y r� l� dog/ems �••p
4.Date Well(s)Completed: 3"I'��" ,•�s Well ID# r-r.51s- ee�,,j ft. )it d 1f4 Av.-k., 01' !e`Te
5a.WellLocation: Phone #3o1_ Z�, y--is-96 ft ft.
&ay le. L ex r1_frf0 .
ft. ft. a I V F} 1
Facility/ID-finer Name Facility ID#(if applicable)
ft. ft. ����/ ■ L
It/ Atev Pc( e RI Hodii5t di-t., )
7-3
Physical Address,City,and Zip ft. APR Lu
/ 21.REMARKS i r:".:,a ,te J 1:ni
County Parcel IdentifrcationNo.(FILL) l ifi,::a: L:ir'�'
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification: •
36`1' 002: Zi $L N gOe' .-KO., -35:7 w� Signiii^eig ---/p46,114
f Ce ed Well Contractor Date
6.Is(are)the well(s): 19Permanent or ❑Temporary
�� By signing thisform,I hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11V o ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and erplain 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:
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
(add See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: / B 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below Iand surface: �7 ' (ft.) (�Submit this GW-1 within 30 days of well completion per the following: `
For multiple wells list all depths fdifferent(example-3 t©200'and 2@100`)
,t y0' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7 (ft•) I�rration Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+" •
Bit Off: /'°oS .. 24b.For Injection Wells:Copy to DWR,.Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA (t
s Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /i Method of test: 44-iii,: rii,6
70%HTH �J' • OZ DATE SITE VISITED: I`G'- 2-3
13b.Disinfection type: Amount: a�'
VISITED BY: PT6. rsoNci