GW1--05123_Well Construction - GW1_20230818

oNS TR)[JCTi'ON RECORD' `t NV-1 For Internal Usc Only: I
.Well Contractor Informntion:
dot u I t> 14.WATER ZONES
FROM TO DESCRIPTION
Well Contract Name - 7t) ft, .9 r ft. 7 if'
acie ft. f.
15.OUTER CASING(for multi-used wells)ORLIINER(if applicable)
NC Well Contractor Certification Number DIAMETER r rffieEQtEss TE• FROM k TO
YADKIN WELL COMPANY,INC. • ft R. .in,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
a a ."ps ®� 0 0 ® yp FROM TO DIAMETER THICKNESS MATERIAL
2.FVellConstructionPermit#:Wet �iID 1/r ft, 5,4pit 1°
o%i
List all applicable well construction permits(.e UIC,County,State, arlanee,etc) •
fr ft. in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply)
❑Residential Water Supply(single) It. ft. i" I
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑Wells>100,000 GPD FROM TO MATERIAL
��/�? EMMPLACEMENT METHOD&BAMOUNT
❑oniWatn ft.•. 1'1-1.d�yny Kern 7 !d i9 ei9*/ /(
Non-Water it. ft. h
❑Monitoring - .. . . - -- DRecovery .
Injection Well:, • ft. . ft.
❑Aquifer Recharge ❑Groundwater Remedialion .19.'SAND!GRAVEL PACK(if applicable) .
❑Aquifer Storage and Recovery ❑Salinity Barrier . FROM TO MATERIAL
EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Subsidence Control ft. it.
•
❑Experimental Technology
20.DRILLING LOG(attach additional sheen if necessary)` • -
;eothermal(Closed Loop) ❑Tracer FROM TO s DESCRIPTION(color,hardnds,!entreat type,grate sae,etc)
❑Geothermal(Heating/Cooling Return)r� ❑Other(explain under
#21 Remarks) 0 fr. s-c) ft. j®.'L
4.Date Well(s)Completed: 7) ' ? Well ID# 4/TI� "745 1-0 ft. • q ft. A ���.`
Og ft. y� fLorn -ram -F°on° 'F'
Sa:Well Location: Phone # ft. ft. //� _
j� u ft. ft. ®_ e 1d `
t+e— �s Facility ID#(if applicable)
Facility/Owner Name- • ft. ft.
ft, ft.
ts�inv... s:-_
21.REMAnus
Physical Address,City,and Zip ::v... " �r�CSYldttiq�Jrtia
(
r : ParcelIdenti5eationND.(PIN) • BORES. .(2) DEPTH..•(35 .2.. ` -'- j/
couaiy -... _ --- DID .OF LOOPS( � / .
# LOOPS PER BORE ( (- ) 4
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: SDR OF LOOPS (�� )
(if well field one tat/long is sufficient)
. 54 N - S P •5311 �( w f, ifa 7
Sign »` of Cc .ed Well ontractor Date
6.Is(are)the well(s): @¢ermaneot or DTemporary
By signing this form,I hereby-cer*that the well was(Were)constructed in accordance with
7.Is this a rdpair to an existing well: ❑Yes or l'to ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that o copy
If this is a repair,fill out!mown well construction Information and 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 MCI*form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well cortstIetion info
8
c.s r Geoprobe/DPT 1 l or Closed-Loop Indicate TOTAL
Wells NUMhavinBER
the ells (add'Sec Over'in Remarks Box).You may also attach additional pages-if necessary.
construction,only 1 W-1 is needed. TOTAL NUMBER of wells '
drilled.. 9 '5- 24.SUBMITTAL INSTRUCTIONS
I I 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(([different(example-3Q200'and 2ta I oo)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:_ (f t•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
l ll1 Ifwater level is above casing,use"+"
/,, Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
' 11.Borehole diameter: `i (In) Program,1636 MSC,Raleigh,NC 27699-1636 • -_-_
" , AIR ROTARY
12.Well construction method: •
•24c.For Water Supply and O• pen-Loop Geothermal Return Wells:Copy to the
I' (i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i' FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
3 `�G y®d PermitProgram,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)_
Method of test: /�" ®a 1 ' .,
13b.Disinfection type: 711 Amount:
OZ DATE SITE VISITED: 3-t O
VISITED BY: b
Price:'; 14nrth rarnlina n.na,�,+.•nt nr F,,uimnn,.nlnt n„o8h,_n:.dr;nn,.r ul,,_-D..,..-....