GW1--03118_Well Construction - GW1_20230428

W CONSTRUCTION RECORD QW-1a For Internal Use Only;
1.Well Contractor IntfoDrruntion:
e�0CI&I 14,WATER ZONES
WeII Contractor N me FROM To DESCRIPTION
S 9g3It. Jo'� e*�4,,^w
ft, ft.
NC Well Contractor Certification Number
IS.OUTER CASIlVG forIIiulti-casedweDs ORLINF.R ifa Iicable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
Company Name
ft, " t , in. / f
+�r 36.'JNNERCA91NGORTUl3 Grp,eothermal closed-loop)
2.Well Construction Permit#: 7 7 3 S l FROM To DWIRTE THIC Ms nzATERrat
List all applicable well construction permits(z e.UIC,County,state,TParianca,etc) j ft ft ���iu. a�f VL
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
❑Agrienitnral ❑Mlln1G1 a1/Pnblic FROM TO DIAMETER SLOT SIZE THICIalfESS MATERIAL
P ft. ft, in.
❑Geothermal(Heating(Cooling Supply) 4esidential Water Supply(single)
ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ;19.GROUT
❑IIri ation ❑WOIIs>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. " ft, P&-e h` ®����
[]Monitoring ❑Recovery it ft.
Injection Well: 9 �`�� vsvi l*f
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
[]Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if a liable)
FROM TO MATERIAL EEffLACGMENTRIMMOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothmmal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under421 Remarks) EOM TO r DESCRIPTION color,hnrdness,saulrark ain sire,dr-
��II
� ft4.Date Well(s)Completed: AA P —c }i ft• S or"
Sa Well Location Phone# 7O 1i-1Y3 r1,—&i( ft. 7, �
A.Ly1 go Je. , ft ft
Facility/OwnerName Facility IDA(if applicable) ff. ftL'Y V v 1^�
—�LS ��j�'1�-O T°� J. ��tw Ir�C�J ft. n n ' 91
Physical Address,City,and lap L T� ft f.
G 6 l�r` i�� ZI.RF.IKARKu' S.. w^�i nn v:-c0QrA-4 Pli�
County— 11 / Parcel IdentifoationNo.(PIN) DVtQi3OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
34;
6.Is(are)the well(s): KPermanent or ❑Temporary Si e of CerfififfWeU Contractor Date
By signing thisfarm,I hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or tNo 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction,Standards and that a copy
If this is a repair,fill out 7orown well construction information and explain the nature of the of this record has beenprovided to the well owner.
repair under f21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 NUNM13R of wells (add'See Oven'in Remarlm Box).You may also attach additional pages if necessary.
drilled: 6
® 24.SUBM�'Tei•INSTRUCTIONS
9.Total well depth below land surface:. � v�_ ft.
Far multiple wells list all depths/fdiffermt(example-3©200'and 2Q100D (' ? Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:_ 7
�� (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level Is above casing use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter.: (in,) Sit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NC 27699-1636
12.Well construction method: AIR ROTARY
(Le.auger,rotary,cable,direct push etc.)
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WF7•T.4 ONLY: 24d.For Water Wells producing over 100 000 GPD• Copy to DWR,CCPCUA�(
13a.Yield(gpm) Method of test: t Permit Program,1611 MSC,Raleigh,NC 27699-16I1
�a
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: .9— \�\1����////�{�•f/
Uri rr a r I eA ,.VWl;TED BY: v B . (�\