GW1--03347_Well Construction - GW1_20230516

bi s CONSTRUCTION RECORD CGW-1 i For Internal Use Only:
7.Well Contractor 7naornation:
£e/ P 14."WATER ZONES DESCRIPTION
p FROM TO �j
Well Contractor Name i �ft. ! ft• r�,,i i �Ci`aa C t'tan ' r���9�1 C�(ed"
d ft. 9 ft.
• (if a licable)
Well Contactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER P)
FROM TO DIAMETER 1 1 CKNESS MATERIAL
YADKIN WELL COMPANY,INC, ft, ft. I in. •-�-�
Company Name 16.INNER CASING OR TUBING Geothermal dosed-loop)'
Z 3 C(/ f FROM TO DIAMETER THIQINFSS MATERIAL p
2.Well Construction Permit#: `1 T / g, u.y; fa to 'n• vii ��I•1
3p
List all applicable well construction permits(.e.f17C,County,State,Variance,etc) .IL
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIAVCSS MATERIAL
❑Agricultural ❑Municipal/Public
ft. ft. in.
l7Geothermal(Heating/Cooling Supply)
Residential Water Supply(single) ft, It. in.
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT EMPLACEMENT METHOD&AMOUNT FROM TO MATERIAL
❑�-�� ❑Wells>100,000 GPD 51 aa ( °g-t*,'if�"��
D ft. ft. Zert 01i��'ej t1
Non-Water Supply Well: it. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK(if applicable) METHOD
Barrier FROM TO MATERIAL❑Aquifer Storage and Recovery ft. ft.
❑Aquifer Test ❑Stormwater Drainage
OSubsidence Control
ft. ft.
❑Ecperimental Technology
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) l7Tracer FROM TO DESCRIPTION(color,bardness,soiltrock type,grain she,cta)
❑Geothermal L
(Heating/CoolingRetum) ❑Other(explain under##21 Remarks) 7� " 'ft. I ft
-.3�3 Well ID � "
#,44 �7 V f, a3 3 5 SOW
4.Date Well(s)Completed: et • ich
W.1C
ft. M�,� �,4 rg "v���., L
5a.Well Location: Phone # 33G4 7/�0 y 33 ft, 3da% ft. �.C.:.t �'- i -- r;'Ji
ft. ft.
5 .i '
14 /�+A 9ti n
L
+ I Facility ID#(if applicable) M�n•Y n U' ln1LJ
� Facility/Owner ems ft. ft.
pM tf t ' 0 - ft. ft, lfli::;i aii.::,t2n Pr:^;-:*--z::',3 I.10
Physical Address,City,and Zip 21.REMARKS ,�,u 73
�,5 i!Di 4 fit! p rr M 11- m!�{-ice oaf
County Parcel Identification No.(P!N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwell fie t tild,one lat/long is sufficient) L-7.o
= i Signatnr Certified Well Contractor. Date
6.Is(are)the well(s): ermanent or ❑Temporary
By signing thisform,I hereby certI9 that the wells)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
of this record has been provided to the well owner.
If thLs is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having NUMBER ofwells same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
action,onlyis n ed. Indicate TOTAL24.SUBIVIITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: `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 2Q100')
24a. For All Wells: Original form,, to Division of Water Resources (DWR),
6°
10.Static water level below top of casing: (ft.)t') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" Bit Off: I :L�I 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
•
AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.Well construction method: county environmental health department of the county where installed
(i.e auger,rotary.cable,direct push,etc.)
SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
( FOR WATER S t Permit Program, MSC,Raleigh, C 27699;16111
; 13a.Yield(gpm) Method of test: t:�i�V _
o OZ DATE SITE VISITE
13b.Disinfection type: 7D/o HTH Amount: 0 l/ • �a
. f VISITED BY: Y
Revised 6-6-2018
i Environmental Quality-Division of Water Resources ---_---- ---