GW1--04466_Well Construction - GW1_20230710

1 ; • ".ONSTR'1UCTION RECORD (GW-"fl For Internal Use Only:
contractor Information: ..
•
'+ I `fa I L Cave 19.WATER ZONES
Well Contractor Name FROM To DCIIIPTION '
3 c- 4 A. J1 ft, $y? ft , 14 6 PM �I
NC Well Contractor Certification.Number ��� ft. �6 `��� ���
15.OUTER CASING for multi-cased wells)ORLINFR(if applicable) r
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL 1/...h,
ft, ft in. Z
Company Name 16.INNER CASING OR TUBING a•m (geothermal closed-loop)_
_ p -Z.Well Construction Permit#: � •- �' �3 DIAMETER THICKNESS MATERIAL J FROM TO _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) L j ft ei ft 49s °�+s�in. SDA�1 PV _
3.Well Use(checkwell use): ft ft. in. V
Water Supply Well: 17,SCREED
FROM TO DIAMETER SLOT SIZE THICI(NESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft, in.
kGeotherma](Heating/Cooling Supply) residential Water Supply(single) • ft, ft. in. j
❑Industrial/Commercial • •DResidential Water Supply(shared) 18.GROUT •
Dlrrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: ft. 3 ft. fj fr1 bi -c Ci jai-
r❑Monitoring ❑Recovery ft. ft. ff t 1 ��r��
Injection Well: � I Tv�it�t +"(�r7 pki,�rbP fds'i
['Aquifer Recharge ❑GroundwaterRemediation ft. ft.
19.SAND/GRAVEL PACK(if applicable)
DA quifer Storage and Recovery ❑Sslinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD .
DA quifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. •
['Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothrrmal(He ting/CoolulgReturn) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(calor,hardness,soil/rock/rock type,grain size,eta)
.1a✓ f a
` 6"lO- - 'j '� ft. Fait . '
4.Date Well(s)Completed: 6112123 We11ID# 144-p'-.2't7 ft. 17 ' •
Sa Well Location: - Ph e # L¢ort 108_ o3. 'n 't 47 hei5e Kaik . ' '
• M4A ticf' / //rrra6' ✓;Arta: STt ft. 9t43 ft �...d -b.. .0 iJ/$' H
Facility/OwnerName Facility ID#(if applicable) ft ft.
ft• •; &" 9J- W 6 a'b ale"' ft. R� .. -
Physical Address,Clay,AM Zip ft ft
A`E r,ky v 21.REMARKS ..
County Parcel Identification No.(PIN) j'�i I v L�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tn;:--r '1 7. `'`''"T'�L'r"_
(if well field one lat/longis sufficient) _)•L4. . ,, '
22.Certification:
56 14 o'l 1( N Fel `-/ , 7 s~s1 W �. ,
6.Is(are)the well(s):,'ermanent or ❑Temporary Signature of Certified Well Contactor. Date
By signing thisform,I hereby cer1i'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or AND I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy.SU,
Ifthis is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair wider#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.constiirct or info '
(add'See Over'in RemarlI Box.;You may,also attach additional• es•ifnecess �'`
conshuctioD,only 1 GW-1 is?ceded. Indicate TOTAL NUMBER of wells ) Y. P �3+. �_
drilled; e t
t,
24.SUBMITTAL INSTRUCct�ONS•.
9.Total well depth below land surface: 9 q3 (ft.) ,-;,, ; ,•
For multiple wells list all depths ifd erertt(example-3Q200'and 2©100) Submit this GW-1 within 30 days'of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.ftic water level below top of casing: (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water water level is above casing,vse"+" a•
Bit Off: S'. 7 8) 24b.For Injection We•lls;Co to D UndergroundInjection (ll.r
11.Borehole diameter: (y (in.) 1 _Copy DWR_, Control J.:
• Program,1636 MSC,Raleigh,NC 27699-1636 '.
AI 'ROTARY
r.- 12.Well construction method: 24c.For Water Supplyi:nd Open-Loop Geothermal Return Wells:Co to the
t�Q (ie,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed Py
FOR WATER SUPPLY WELLS ONLY: 24d-i•rar'Water Wells pi'oi'i.i=ing over 100,000 GPD: Copy to DWR,CCPCUA
�+ t Permit Program,1611 MSC;•;:;; igh;NC 27699-1611
13a.Yield(gpm) <J __. Method of:est: l�,f
•
• 13h.Disinfection type: !0%H'I H Amount:. 07_ DATE SITE VISITED: Z:�--/(''.2 2
PrinP_
I _ L VISITED BY: 1/6