GW1--05230_Well Construction - GW1_20230818

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�LCONSTRUCTION RECORD(GW-1) For Internal Use Only: --'6
1.Well Contractor Information: r 1 9
Ad 1� Ryes 14.WATER ZONES ^S
Well Contractor Name FROM_ _TO DESCRIPTION C
it,. i' 1 ft. t Auw-r PIA fuN of iron
NC Well Contractor�� cation Number S� ft. %la ft. ,aM fracture 9,75 6i3Y twr- S
15.OUTER CASING(for multi-eased wells)OR LINER(if op licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS �. MATERIAL
Company Name
ft. /' ft. /in.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: U Ai FROM TO DIAMETER THICKNESS MATERIAL 7
List all applicable well construction permits(i.e.UIC, ant Slate,Variance,etc.) _/ )ft' 11 a ft 7 m' 140 cif, 5)acyc p
3.Well Use(check well use): TIC f ` ft '� '1 d'`� (!6 ``
Water Supply Well: . 17.SCREEN g
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .0L
❑Agricultural ❑Municipal/Public ft. ft, in / / j
IGcothermal(Heating/Cooling Supply) Ntesidential Water Supply(single) ft, it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑litigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D !t, Atf fG Zy Chit d'"',si / 10./3145
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPI.ACEMENTMEPHOD .
❑Aquifer Test ❑Stormwater Drainage ....7-.'......-)/'t
❑Experimental Technology ❑Subsidence Control ft t
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardncu,unfrock type,grain Axe,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remains)
5,1I;„r 1...z..z 0 ft. 110 ft. so(l i
4.Date Well(s)Completed: 7`1�✓1,3 Well ID#AA FA- -`-a?. 190 ft. 45 ft' 5„,„t 6 Iwl krrAs _
Phone # 33i-A Gl/793 It S ft. 85 n Mid i Tra:
5a.
Well Location: a111' •
illAt n Yethr6 ( pS ft' ill ft' very - gR#hae _
acrfity/Owner N e Facility 3D#(if'applicable) I 4 I K fi IL "lea stmilt
3 5.1 pa 41 .ite, -M dq. Il ioa 1oa0. f f- I i 3hJ-erey 6ftfalite.
Physical Address,City,and Zip
LI-I. ere- - 21.R Rue, L(�J
County (� Parcel Identification No:(PIN) h i 1 I/b IC) of / (- y o 1 t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - �"- y ,
(if well field,one let/long is sufficient) 22.Certification: v i
3f Or,ag33 N 8I /1, ($ 2' w AUG 1 8 2023 7 17^013
6.IS are the wells: ermanent or ❑Tam or Signahu of • a ontractor ,.,
Is(are) () � p �y lt:�Cfat'a►�:rt r'f.^C:4441"a @S6
By signing thlsform,I hereby certify that,the wellrs)Noaglactonstructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ocrio l5ANCAC 02C.0100 or 1544 NCAC 02C.0200 Well Construction Standards and that a copy
rats 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#21 remark 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 Sec Over''in Remarks Box).You may also attach additional pages if necessary.
drilled' L 24.SUBMITTAL INSTRUCTIONS
0.5A ,
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completiong�
per the following:
For multiple wells list all depths if different(example-3(4)200'and 2©100) y p
rl • ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: , '1^ (ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+' Q2
• 11.Borehole diameter: 6 (in.) Bit Off: 5 s /tit i 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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
/0 Method of test: �L/lie
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: .� i`2 2
Pr;r-P 0 Z el/�as TED a Vag39