GW1--05125_Well Construction - GW1_20230818

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' --' °:Et iL CONSTRUCTION RECORD(G117-11 For Internal Use Only:
I.Well Contractor Information:
2)ecii 64a'il•KiAi5 14.WATER ZONES
Well Contractor Name PROM TO DESCRIPTION
J� ft. 70 ft. ry
2LIS3 ft. ft "' !
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable) °6"4
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL ='M
ft ft. in.
6.mpany Name
_16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL ?`'�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) . ft. Li ft. O fq in. ,st RD i Pi L /�L
3.Well Use(check well use): ft. it. in. To
Water Supply Well: 17.SCREEN
pp Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. ft. in.
❑Industrial/Cornmercial . ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D it' 3 ft- Uoie QIu5 £urd -a 64,s
❑Monitoring ❑Recovery 3 ft, O ft Out Y7rod etaf.a Pd P�/Z lx l
Injection Well: ft. ft. t
- DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bather F.RoM 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(solar,hardness,soilirnek type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain unddeeerr#2211 Remarks)/ J-
ft• 30 ft
4.Date Well(s)Completed:
1's'I312'3 Well 1D#//.-r ! - Yana 3.3 ft I303 ft- Co)/
Gegl�+, r�1
4.
5a.Well Location: Phone# .7.94-8��-'0 .1 ft ft.
Ee 4 '-.. teaft, ft�c /Q �s
Facility/Owner Name Facility ID#(if applicable) ft ft. R(,�tr C.A 1, Ir-C'-k
ft. . ft.
Physical Address,City,and Zip�$ ft ft. A U G 1 8 2023 '€-+
kr /e 21.REMARKS ink:Ana:ion PrcC
iosini County Parcel Identification No.(PIN) rs d CZ;: V►t 6
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _+I
(if well field,one lat/long is sufficient) 22.Certification: /13
34 , 3, S.2.4/0 N 9/ Z40339G W eo f i 2 i 3 .
6.Is(are)the well(s): eermanent or OTemporary
Signature f Ce ''ed Well Contractor Date coo
By signing this fonn,I hereby certib)that the well(s)was(were)constructed in accordance with -
7.Is this a repair to an existing well: ❑Yes or ftfo 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a 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 1121 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 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: `/ 24.SUBIVIITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 3®3 (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),
10.Static water level below top of casing: �V (ft') Information Prcoessing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
' Bit Off:6°��9 24b.Fn ": -_..';,: Wails:
,Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,163'6;vlSC:1?aleigh,NC 27699-1636
12.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
B t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �� Method of test: g� / ,
13b.Disinfection type: 70%HTH Amount: 5° OZ DATE SITE VISITED:_/ /%' --Z3 b,'it `'u ,
- -- .. -- VISITED BY: �6! .
Pri r e
Form GW-1 imenial Quality-Division of Water Resources Revised 6-6-2018