GW1--04018_Well Construction - GW1_20230612

H CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
/k I IA&iv gPO iiiryl 14.WATER ZONES
Well Contractor Name _FROM TO DESCRIPTION
Z1O ft' 2.11 ft' 1
303C, A 3ciJ 37.r- it .s �'
NC Well Contractor Certification Number 16.OUTER CASING(for niulif-cased wells)OR LINER(if a licable)
YADKIN WELL COMPANY,INC. FRO TOr 7.7_DIMETER.m T$?�EssMATEA� (�
Company Name p/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit it:
: 3 ® 6 it?6�/ FROM TO _ DIAMETER Tz ICE-NESS _MATERIAL
List all applicable well construction permits(i.e.t1IC,County,State,Variance,etc) .4.-/ft //9 ft L�/ Yee in. S,12_�� fife ` °
3.Well Use(check well use): ft. / ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgicuIturaI DMunicipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) yip esidential Water Supply(single) it. ;n,
DIndustrial/Cornmercial DResidential Water Supply(shared) 113.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-Non-Water Supply Well: 0 ft 2 g ft. e,..1 QivAL eiii 6 Py `5-
❑Monitoring DRecovery ft. ft.
Injection Well:['Aquifer Recharge ❑GroundwaterRemediation SG/ " Genf pu Se 1b FN./S
19.SAND/GRAVEL PACK(if applicabl e)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage
['Experimental Technology ❑Subsidence Control ft it / lre..--'----> V
['Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/racktype,grain size,etc.)
4.
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) q ,.t
4.Date Well(s)Completed: t/d/ a 3 Well ID# 11-Ab `3 Y9 //d ft 9Z a. 6 F:"-e, _
Sa Well Location: �� f. ft ;
Phone #3,3K-1 g77- .. L N 17?. 1t -. i
• hi if C k A 7'//cljr' ft. ft
JI
ft. ft viAV � � 1U��
Facl7ity/OwnerName Facility Mil(if applicable)
ft ft nS cmntt�l ?r:. .
al/ 3e4vel' 4, Gi/ v�i� I mod, ;. 4 ur2
Physical Address,City,and Zip It J4-d 4,‘.., fkl�y,¢ft, A zero c.A 'i
A _21.REMARKS
County �� (PIN) �1 iA e H1 0)4 0 4 p A L ' ''® 4'& T F!"�,f
Parcel Identification No. f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '' i c 3®r '/114i.,t1
, (if well field,one lat/longis sufficient) 22.Certiification:
6.Is(are)the well(s): permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certiO that the well(s)was(were)constructed in accordance with
"e
7.Is this a repair to an existing well: DYes or °I�jNo 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 Actexplain the nature of the of this record has been provided to the Well owner.
repair under#21 remarks section or on the bock 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: ( 24.SUBMTITAL INSTRUCTIONS
L`
9.Total well depth below land surface: (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 2Q100)
9 7Aa. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ifwater level Is above casing,use"+" A
11.Borehole diameter 4 (in.) Bit Off: b ^ 0/Z 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
v.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: •. ,�G/r Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH 3 OZ DATE SITE VISITED: /1 ® /5®a
13b.Disinfection type:. Amount:
Price: 1 VISITED BY: Ve
n„,,,,t:W-1 rental Quality-Division of Water Resources Revised 6-6-2018