GW1--04408_Well Construction - GW1_20230710

5
I,.I,L,CONSTRUCTION I�t,'COR(GW-11 For Internal Use Only:
4.Well Contractor Information:
lii sly A 1 . : 19.WATER MINES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number �OUTER CASING(for multi-cased wells R LINER(if appicable) 1.A r
YADKIN WELL COMPANY,INC. FROM TO DIAMETER 1 THICKNESS MATERIAL A
ft. ft. in.
Company Name C
16.INNER.CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 it 1. i9 311r FROM TO DIAMETER THICICNESS MATERIAL
List all applicable well construction permits(e.UIC,County,State,Variance,eta) -l 1 ftp)+ ft' k r®�-riu' ,fJ 4.- /Q/G
3.Well Use(check well use): T ft. ft. in.
Water Supply Well: 17,SCREEN E
FROM TO DIAMETER SLOT SIZE TmCENEss MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in. i
OGeothermal(Heating/Cooling Supply) ktesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT °'i
❑Irrigation ❑Wells>100,000 GPD - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: b ft. 9' ft- r-ddLa,s puts rev
OMonitoring ❑Recovery e/ it ?),°ft 5,1111-y ieii ,,,p,0
Injection Well: `
ft. ft.
DAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(ester,hardness,ssilhock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)rk U ft.
7��$. S®e
4.Date Well(s)Completed:4'2k' ?3 Well ID# AA, ^Le. 3 7 ft. 3 t- ',leg' i� hy bird =70'
5a.Well Location: Phone #`ll f-4 l4-`7QQ4'/ ft ft -- -
ft ft.
1i).1'itet 1,1,17-Tofi0,r2t
Facility/Owner Name Facility ID#(if applicable) ft. ft (- ; ; �- ^; { ;7-)-,
e� Nye. a. R d La ,.if -5 ,,tly ft ft. i _.t-,•s-a . 5 . r
Physical Address,City,and P N C s1`s(.ii 4d,{ T ft. ft .1111 1 9 ?('?.1
iile.(� �pq 21.REMARI{S 1J c..iv,-(,•. Pr^^ra .g Ur.k
Coon ! Parcel IdentificationNo.(PIII) Ir' �.t O • G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
36 fig, k67d N 81 1,5 5.-Q. E3 W t1 da& 4 ,)-)-d2-3
6.IS(are)the well(s):APermanent or ❑Temporary Si
gga� of Certifie ell Contractor Date
BySSsiiggning this form,I hereby cent),that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or fto 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 and explain the nature of the of this record has been provided to the well owner.
repair under il21 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 GWg1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
a
9.Total well depth below land surface: 3.27- (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(ezample-3(5200'and 2©100)
© (ft.)*? 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: P Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Bit Off: °0 e 24b.For Injection Wells: Copy to DWR,Underground Injection Control (MC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636 e
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 •
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA C
/ iN Permit Program,1611 MSC,Raleigh,NC 27699-1611 t;
13a.Yield(gpm) FJ Method of test: ng; / Q
cDATE SITE VISITED: 1 `/ ®^43 '
13b.Disinfection type: 70/o HTH Amount: �e 0 oz , /
Phi cP o �___ �_e- - -- + VISITED BY: v e v
kta
v......nw_r 'mental Quality-Division of Water Resources Revised 6-6-20I9