GW1--03922_Well Construction - GW1_20230612

e --' ".ONSTJR'UCT]ION RECORD (GW-1)) For Internal Use Only:
•-�``�Jontractor nformation:
4 " ' " - Ste Asa 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
.3u , � 17v ft. i7e ft'..... 1/4
Lis-0 ft. sirs- ft a t®q, �.3
NC Well Contractor Certification Number 15.OUTER CASING(for mTulti-casedwells)OR LINER(if ap livable)
YADKIN WELL COMPANY,INC. FROM TO / DIAMETER THICKNESS MATERIAL
Company Name ✓ R / in.
1l.06 Il�NER CASING OR TUBING(geothermal closed-loop) 0
2.Well Construction Permit#: 464THICKNESS MATERIAL _
List all applicable well construction permits(r,e.r1IC,County, fate,Variance,eta) +(ft AT ft ‘ ill/4i i°. rp,gy- d 1 !)v C.
3.Well Use(check well use): fir ft X.® ft. 6 rise in. 0.itrn _6dfv $d I
Water Supply Well: 17.SCREEN '`j
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft � in. � ,,,,, t,
❑Industrial/Comerciai DResidential Water Supply(shared) 18.GROUT �-
rn
Dlrrigation DWells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 0
V
Non-Water Supply Well: p� it ,21 ft-. �4.1.��.- a�_, 6-4vli 174
OMonitoring DE ecovery ft ft.
Injection Well:
ft. ft.
DAquifer Recharge DGroundwater Remediation-
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft /"
DExperimental Technology DSubsidence Control ft it J
❑Geothermal(Closed Loop) ❑Tracer 20.MULLING LOG(attach additional sheets if necessary)
❑Geothermal(Healing/CoolingRetmn) DOther(explain under#21 Remarks) PROM TO DESCRIPTION{c°]°pprr,hardness,soi1Irarktype,grail]size eta)
Sited at,Q.;.r/.r/.2s ® ft eJy ft 501 </ /iOL/L, 6v1Y,v�9
4.Date Well(s)Completed:41,2 6/.23 WellID#/r/fP 'D--37 if', ft. S'®.2. it A� �/
ft.5a.Well Location: / Phone #Bq4'-‘? -4yr4, ` �. ..G- ..i l;f d;�'i_
( ;,4 /7��4 GI)0(xi.fey ft ft 1 u N 1 0 9 n o l
Facility/OwnerName J Facility ID#(ifapplicable) ft. ft ��`�J
lDO �u -?te. /e 1 �e' S ft ft. InfiB7r:�s t�n Pr r..-:;:- Una
Physical Adddress,City,and lip AS bcB�i t
- ft f
/t/G��. /--et v 21.REMARKS
County Parcel Identification No.(PM) Si. # 44". (o r,.,v 43 ,gte-7/ Ca y'q •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one let/long is sufficient) 22.Certification:
3 ' /0, 3..2z a N g'J 4( 7, G 44? z- w
6.Is(are)the well(s):‘fr ermanent or ❑Temporary g s� ^ t��- Date
Si afire of Certified Well Contractor
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or , No 15A NCAC 02C.0100 or ISA NCAC D2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark.section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: I ®� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft.
For multiple wells list all depths ifd Brent(example-35200'and 2@100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: i/O (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.EOrehole diameter: , (in.) Bit Off: " ®0`r" 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) k.
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
(ie.auger,rotary,cable,direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the e
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GED:Copy to DWR,CCPCUA £
Permit Program,1611 MSC,Raleigh,NC 27699-16I 1
13a.Yield(gpm) 3 Method of test: ‘:? 1,,, RA
13b.Disinfection type: 70°%HTH Amount: Z 4 OZ_ >DATE SITE VISITED: Cl Q C.-�L •
y' t? -
Form GW-I 1 -