GW1--04023_Well Construction - GW1_20230612

4ro_®'`l:CONSTRUCTION RECORD(GW-11) For Internal Use Only:
‘--- 1..1�'- ell Contractor Informa•tion:
- t!fl i tA `•p&4k i S 14.WATER ZONES.. .. I
Well Contractor Name .FROM TO -l '`DESCRIPTION 1.
11
Lisa AS'7q ft. S8Oft. 2 C Prei. rr'
fc. ft.
rig
NC Well Contractor Certification Number IS.OUTER CASING(for multi-raced wells)ORLINER(if ap limbic)/ YADKIN WELL COMPANY,INC. FROM TO DIAMETER ��SS 1 MATERIALIIIII
ft. ft. in.
Company Name 16.INNER CASING OR TUBING
Re, (geothermal closed-loop)
2.Well Construction Permit#: 3 Re, 1/CrC FROM TO _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) 6�6 ft V t ft G 1/Y in. SARI1 PV C.
• 3.Well Use(check well use): ft fr' m '1yr,1
VI
Water Supply Well: 17.5CREEN
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Publio ft. ft. ' I in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) • ft ft. in. TO
❑Industrial/Commercial . DResidential" Water Supply(shared) lti.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO .1 :MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft'. 3 fti 1-6 if P103 Fob,red 2112 •
' ❑Monitoring ❑Recovery 3 ft ,aJ ft. Q„tc C,ro,( Puwpcl Li Y2
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation 79.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control • ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Rehm) ❑Other(explain under al Remakes) PROM TO DESCRIPTION(color,hardness,soil/rock type, s sire,etc)
❑Geothermal(Heating/Cooling Re
Sib ft. 73 '' S®/Y
S
4.Date Well(s)Completed: g 1 a-3 well ID# P-3 j y -73 t L-a 2 t C ca.,it
5a.Well Location: Q Phone #3 Pi,-5ze-'l3JCG ft K
® 6 e ft ft rl E ° - V r. _
Facility/Ow Name Facility ID#(if applicable) f. ft �I\'.-4.`r i v 1...11.1
ftb eccoh. 1. ns), CA- YrA JUN 1 2 2023
Physical Address,City,and Zip ft ft.
E .r.kiril Prrr f. w�atwn:L'el
/4'I/ /J 7 21.REMARIGS �'1r .:;':'3
County /[ Parcel Identi{cationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r.
•
(ifwel]fold,one let/longis sufficient) 22.Certification:
3423 CS
, JV, /if 3 N Certification:_
4 O B' w ..�
6.Is(are)the well(s): Permanent or ❑Temporary Sigoata of C ed Well Contractor Date
pc
By signing thisform,I hereby certify that the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or Io i5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy V'
If this Ls a repair,fill out brown well construction information and explain the nature of the of thts record has been provided to the well owner.
repair under#21 remarks section or on the back of this faTm. 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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 22 (ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3()a 200'and 20100)
60 24a. For All Wells: Original form to Division of Water Resources (DWR), d
ID:Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing use"+' 'C
11.Borehole diameter: 6 (in.) Bit Off: S,7©9 0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
11 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,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: det, Ile Permit Program,1611 MSC,Raleigh,NC 27699-1611
ai
13b.Disinfection type: 70%HTH Amount b 4!j OZ DATE SITE VISITED: e`-Z,.. a.
- ari'eP� 1 VISITED BY: g
Ferns GW-I.; ma Department of Environmental Quality-Division of Water Resources Revised 6-6-2018