GW1--04417_Well Construction - GW1_20230710

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•vV) LL CONSTRUCTION_RECORD(GV1-1) For Internal Use Only:
1.Well Contractor Information:
,)�.�. Pi 14.WATER ZONES
E PROM TO DESCRIPTION
Well Contractor Name ft
/_
ft. 6ft JI
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO -DIAMETER THICKNESS MATERIAL E
ft. ft. in, (�
Company Name / 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 4l/P l 73 FROM TO DIAMETER =cal rss MATERIAL'-
List all applicable well construction permits(i.e.MC,County,Slate,Variance,eta) !�l ft 6,3 ft L2 in. /_U++ sit( edit` 1A1
i
3.Well Use(check well use): ft ft. hi.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. I
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) • ft ft. in.
Dlndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IIIigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMIINTMETHOD&AMOUNT
Non-Water Supply Well: .b ft 34 ft. I3 tiMi j 0r)fy01 ato tia35,
❑Monitoring DRecovery ft. GG ft. ,
Injection Well: ft. ft.
❑Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. IL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
d h l
TO
DESCR FROM
❑Geothermal(Heating/Coolmg Return) DOther(explain under#21 Remarks) IPTION(coor,hardness,soil/rock type, size,ete)
o ft, y. - ft. .o;( era u s..
4;Date Well(s)Completed: f._)3--e23WellID# 4Ar 3 a / 4a, ft. tlic ft watt-Ile-c) It c
Sa.Well Location: Phone# 5-G/-7OO I- a'{7 9/5 ft I'a2b t ilSik , Ry •_''11bhi i.,
ft ft
• /tA- S-Wee-1.Gy '
Facllity/OvmerName Facility IDff(if applicable) ft. ft
F". '-^.,--rt' r r.
4p 6 7 7 hti frt.(6 GhNy Flj/ ft. ft �:-''� V�c S..a-�r '.-
Physical Address,City,and Zip l h �a210.ra dI Orr_�aS ft ft. I i I 1 1, it 2023
G (dw-,AP-P A• ✓C ®i NY 21.REMARKS J J
County Parcel Identification No.(PIN) Inici r-.ai.a PrC)CS:, . ..:1 l:r;i
D.VC.1's3C\C-s,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlongis sufficient) 22.Certification:
3.0 05, 37G/ N Er/ 3X, a17a. w �� - e 13'a 3
6.Is(are)the well(s): ermanent or OTemporary Signature of Certified We
ntractor Date
By signing thisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1 wo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information d explain the nature of the of this record has been provided to the well owner.
repair under#21 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 GW-1,}s needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional page :if necessary.
drilled: C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /g (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 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
�ryy
10.Static water Ievel below top of casing: /,5 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+"
11.Borehole diameter: Gj (in.) Bit Off: (. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636 .
11Well 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 C.
j ( Permit Program, MSC,Raleigh,NC 27699-1611 ` , C
13a.Yield(gpm) 1„(JS _ Method of test: qd Y _
70%HTH • 5 OZ DATE SITE VISITED: •/° . t C
13b.Disinfection Pe:_ Amount _ t -
�� 4,A I
PrinP•- .. i`
esourees nnviee A 6,-6-9ni a