GW1--03343_Well Construction - GW1_20230516

WELL CONSTRUCTION CO (CW-1) For Internal Use Only:
1.Well Contractor Information:
il
u 1 w s 14.WATER ZONES
Well Contractor ame
FROM TO DESCRIPTION
4,15v ft' '7o ft. So-P÷ Cie 1 a�'9, -4�;
. p 572 ft. ft.A
NC Well Contractor Certification Number rb
15,OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS 1 MATERIAL
ft ft in. •�
Company Name �, 16.INNER CASING OR TUBING(geothermal closed-loop)
.0 LL
2.Well Construction Permit#: rj 5'3 o FROM TO DIAMETER TECIIO ESS MATERIALIA °'''
Variance,etc.) J ft / 3 ft. �4'.1 Sys-in. a PA' ) f 'mac
0.
List all applicable well construction permits(i.e.UIC,County,State, [ (e� 1® O'
3.Well Use(check well use): ft ft. in.
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) ft. ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft 9` ft. 03e4-eA ps p t -rti
/
0Monitoring
Well: ❑Recovery 9 ft. e...3 ft .Stare- p urkrei
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK(if applicable) )
./
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonmwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,taiVrocktype,grain size,eta.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ® ft ft, Se7��
/
4.Date Well(s)Completed:''/1- >3 WellT# /419O 3 s" f 41,0 ft' Sc 'C r'ei 6 ro„v.4e
Sa Well Location: y� I Phone # fjq-77s 8 '30 6 ���°i` vi&d /lard t rt C r
PO ielt4 "lob 4 4 y" r ft ft f_ g� :- v 4
Facility/Owner Name Facility ID#(if applicable) ft. ft ::�. �_:,i..,_i 'l.. j'''*
ft ft.
a !150;C�c„006/ A. /ouch-ri,/ 4. ft ft. MAY 1 v 2vr_.t
Physical Address. and Zip
site, 21.REilSARICS -,:--1 7r ^:k'K> .i lir:f
is n•�,f.,:
County Parcel Identification No.(FIN) -Ael 3b
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
r.1 Ed 0 N g/ 33 f cle7i W ' qv'
6.Is(are)the well(s): [fiff ermanent or ❑Temporary S. a of Ce ed ell Contractor Date
By signing this form,I hereby certj that the walks)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ;Io 1SANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#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
construction,only 1 GW 1 is needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 6 I 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ��2 (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 2©100`)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 2 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"11.Borehole diameter: (lam (in.) Bit Off: 6.0 t7 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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 2
4
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test: at l Permit Program,1611 MSC,Raleigh,NC 27699-1611
y . 6
70%HTH OZ DATE SITE VISITED: / 0- 7--21 / --b`�; -3 t). "1/43 N
13b,Disinfection type: Amount: v
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Pri
.-_ VISITED BY:
Vs rai 7nonmanlal Quality-Division of Water Resources Revised 6-6-201 S