GW1--03342_Well Construction - GW1_20230516

VVF,LJ �NS TRUCTION RICO (G•W-1) For Internal Use Only:
1.Well Contractor Information:
`. _C,G d7 I t i 5
I,�14.WATER ZONES
FROM TO DESCRIPTION
Wei Contractor Name yk.
a5'7 t. �g®,f
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(if ep licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER 1 THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 22
d
2.Well Construction Permit#: 3 D . I 0 0 FROM TO -DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) I`-/ft. 941 it l_,,5-in. 5042.
i p vr� 2
3.Well Use(check well use): ft ft. 1�/ m.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
....) ❑Geothermal(Heating/Cooling Supply) eYLesidential Water Supply(single) ft ft. in. •
a
❑IndustriaUCoinmercia] DResidential Water Supply(shared) 18.GROUT
❑Imgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTM TROD&AMOUPIT �"
Non-Water Supply Well: aft 3' ft- �,�A.ekis ue. d
❑Monitoring DRecovery 3 ft. ate' ft ei,„:5-A furys
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) .'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft ft-
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILIiNGLOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,SOIVR rktype grain she,etc-)
�� Co ft " ft. Sot`/
4.Date Well(s)Completed: q',4 3 well ID#/4�P"3//l-3 Iy r ft. 70 g ft. p''?i e'i 6-0 /,,,„step' ./-r r
iii
s 2/ ft ft Acre.,�
5a.WellLocation: Phone # 33G-G D-0-3�1113
1/ Cif ///D t.t. ft ft
GG �' .- -
Facility/Owner Name Facility ID#(if applicable) ft. ft. �'� 1 ,k�.,a.T e ti,y Ij_,j )
Al,PI 5 gd ft ft.
May r L�,i
ft ft. +� L LJ
Physical Address,LLy, d Zip
r S /ei 21.REMARKS f)..i `Gir✓, n Pr^:�;5,7%, 31?i-0
X. �/ L�, 1 rd ,v,
PdaGCeof ea 4 0-0 - /)-UO Y y©® 'o d 0,d a
Parcel Identification No. Pia yy
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 3 60 0-00- 1
(ifwell field,one latllongis sufficient) 22.Certification:
3 1•Tr. [ I( N z 9A rs°3-2- W �1 4/ t�O . /=aox3
or Sign a of Certi Well Contractor Date
6.Is(are)the well(s): permanent or ❑Tern p ary
By signing thisfonn,I hereby certiO that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information d explain 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:
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 GW71 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 'C y 24.SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 70J a (ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3Q200'and 2QI00`)
• (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+'
11.Borehole diameter: C, (in.) Bit Off: 5'7 d5" 24b.For Injection 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
(i.e.auger,rotary,cable,direct push,eta) county environmental health department of the county where installed 1
6
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA a
At
er -P Permit Program,1611 MSC,Raleigh,NC27699-I611
13a.Yield(gpm) at- Methodod of test: Le ✓ / j
70%HTH 9`7a2 OZ DATE SITE VISITED: ` d"11--2-
13b.Disinfection type: Amount _ 66
VISITEDvie
Pri nQ I' BY:
c-_r_w_1 1 _pia]Quality-Division of Water Resources Revised 6-6-2018