GW1--03116_Well Construction - GW1_20230428

701N S'1i1C UC ION RECORD (GW-2.) For Internal Use Only:
42ontractor Information: _.._I
a%t v " '4 l 1I :.1 14.WATER ZONES
WenContractor Name FROM TO DESCRIPTION
a 57,,)14 9i ft. ?I- ft. s ips.3®8 ft /.Ss-•-l4e - �, j-
NcweuContraomrCerti9oationNumber
j/e it
1S.OUTER CASING•(for multi-cased w OR LINER(if op livable) 1
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER TRICKNEss MATERIAL
Company Name , /t. �m' /
r 16.INNER CASING OR TU_BING(geothermal dosed-loop)
2.Well Construction Permit#: 3 '� I/J PROM TO DIAMETER T 1CIO ESS MATERIAL
List all appllcoble well construction permits(i.e.UIC,County,State,Variance,etc) 4-et- S-7 ft /�1) ia.J s-�l� 1 r
( io,
3.Well Use(check well use): ft. �e
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in / ._
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) • it ft.
, /''
2
❑Industrial/Commercial . ❑Residential Water Supply(shared) t3 GROUT
Obligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. '3' ft. $6,i-cil:es p©4#r41
❑Monitoring DRecovery 3 fft. ft.
Injection Well: -3� Qiiq•aSB Ato�� thirty d�+
ft. R
❑Aquifer Recharge ❑Groundwater Remediation
Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(f Applicable)
❑
PROM TO MATERIAL EMPLACIKITENT METHOD
DAquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology DSubsidence Control ft 7.ft. Z . ,/
❑Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,eoillrvektype,grain alas cte)
a ft. 70 ft. sax/
4.Date Well(s)Completed:S-Pr� We11ID# Pry. 70 ft. /of itri%�/, �`Apt -c 4 -
5a.Well Location: 4 Cagey v hone # /6 3�.Z si.3(�. . / /O5 /I -.SA- &wit fCa 6 k- 0,1 ,
1-4.(k/1,-e<,C- 7 a reP4 //2. ft 3‘7®•ft' ice,t fad . 0...,4#e
Facrility/OwnerName r FacilitylD/I(if applicable) ft. ft
Physical Address,City,and lap ft. ft. t i=L.., I �f 17:'..
//"��h/ 21.RRMARKR
!! / b
County Parcel Tdentdioation No.(PI27)
AFK CU[�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ittfrrfi"a=fin i'r::t;. ;r.g Uri
(if well field,one lat/longis sufficient) ��Pf(�j ��(-
22.Certification:
36- 3It 48/4.( N C® 5i, n s-5 W fr.. to "326.1; .
6.Is(are)the well(s): ermanent or ❑Temporary Sign Well Contractor Date
,,,���n""" By signing thisform,I hereby certify that the wells)was(were)constructed In accordance with
7.Is this a repair to an existing well: DYes or oo I5ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this tea repair,fdl out known well construction information and explain the nature of the of this record has been provided to thews!!owner.
repair under 01 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 Remarks Box).You may also attach additional pages ifnecessary.
drilled: t
1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft.)
For multiple wells list all depths lfd erent(example-3©200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
�s° 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5taticwaterlevel below top of casing: ft � )
"floater level Is above casing,use"+" ( ) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: on.) Bit Off: S_•/3)- `.24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) ril
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636 ��
12.Well construction method: 24c.For Water Supplyand Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,runn
y,cable,direct push,etc.) P P
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
13a.Yield(gpm) 30 �Method of test: qe PemxltPrngraiu,1611 MSC,Raleigh,NC 27699-I611 "
70%HTH -g,7 oz DATE SITE VISITED: - ZZ €31
13b.Disinfection type: Amount: /, AI
VISITED BY: //g
Form GW-1 pnmental Ouaiity-Division of Watwr R renivn.e