GW1--05279_Well Construction - GW1_20230814

W- ,C„NS�li�".I[jd�1^1iTC'i1�RECORD � �-1� For Internal Use Only:
vt41 'ontractor Information:
1144 4-84'. /If � M 14.WATER ZONES •
I FROM TO DESCRIPTION
Well actor Name P! ,eft, ry ft•
3036A 6 ft. j� ft. i - 3
NC Well•;ontractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
YADKI WELL COMPANY,INC.
FROM DIAMETER TEUCtcNESS I MATERIAL
J 5
Compan Name 16.INNER CASING OR TUBING(geothermal closed-loop) 5
Ka: 3FROM TO DIAMETER I TFICICYSSS MATERIAL (1
2.We;1 :onsn::r r.ian Permit#: ®0 q 1 9.a
List all c olicable well construction permits 0.e_UIC,County,State,Variance,etc.) �ft. ft. 1n. S
3.Well Jse(check well use): -` r "
17.SCREEN :t
Water upply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agra Itural ❑Municipal/Public ft. ft. in. �--
❑Geot :rural(Heating/Cooling Supply) ❑Residential Water Supply(single) . ft in. --,/
OIndu• -ial/Commercial . ❑Residential Water Supply(shared) 18.GROUT 1
❑lnig ion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-V ter Supply Well: 0 ft, �oo ft. •I��I y. P,n, ,'�" .20 ,�
❑Mon•oring ❑Recovery ft ft i " '�"" I
Injecti a Well: I ft. ft. 4A �`)Z - (44
❑i 1 sr Recharge ❑Groundwater Remediation I f
19.SAND/GRAVEL PACK(if applicable)
L., a sr Storage and Recovery GSalinity Barrier FROM TO MATERIAL EA2r1.ACLI.a5n...u:,.iOD
❑/ or Test ❑Stormwater Drainage ft. ft.
CT/jot imental Technology ❑Subsidence Control ft. ft.
tiktot'.ermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) tO
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain she,etc.) O
❑Geo••ermal(Heating/CoolingReturn) ❑Other(explain under#21Remarks)
AP� 0 ft. L I ft- So.'O' " . .
4.Dal Well f:' -am pleted• 'CP03 Well ID# 8 .• ft- ft. --- _ 1
5a.W 1 Location: '
Phone # q,31�'^2.w-o/(3 ft. ft. @ '�. .L'L--.. V y t e,,)
5e4 -® _ - ft.' ft.
Facilit )wnerName Facility ID#(if applicable) ft. ft.
lTgi g (<(r v L l' - PoieuidSe - ft. ft. Ire't77F:=4£-1 v�Y;i;', I:Rt \
Physic'Address,City,and Zip
2- O 3( ft• ft.
44, ($-P\ b (/, . 21.REMARKS ,,m��@ t
Parcel Ident�cationNo.(PIN) BORES (i ) DEPTH ( iz V:r/ C(e2 Iz
Count
j
! # LOOPS PER BORE ( 1 ) DIA OF LOOPS(1 .
5b.L:,itude and longitude in degrees/minutes/seconds or decimal degrees:
' (if we)`,field,one lat/long is sufficient) 22.Certification: SDR OF LOOPS (f ( )
Jl
3.51-e 515-0 CION 2'0 "1 l[/ a W/ Signature of Certified Well Contractor D. 6/o?g/d3 cAt,„
ate
6." .'e)the well(s): g rmanent or ❑Temporary v!
By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance with
al
7.Is I i is a repair to an existing well: ❑Yes or 19No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standa.it and that a.copy
If this 1,•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 nder#21 remarks section or on the back of this form. -
I 23.Site diagram or additional well details:
8.Fo'cGeoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
const'i ctio , r'1 GW;a is needed. Indicate TOTAL NUMBER of wells.. (add'See Over'in Remark Box),You mayalso'attae)t additional pages if necessary.
drille. / 24.SUBMITTAL INSTRUCTIONS •
9.To .i well depth below land surface: (ft.) •
Submit this GW-1 within 30 days of well completion per the following:
Form'•tiple wells list all depths idifferent(example-3@200'and2(0100')
24a. For All Wells: Original form to Division. of Water Resources (DWR),
10.S 1/2tic water level below top of casing: �� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwatr;level is above casing,use"+" I
6 (in) Bit Off: S" e 1°° 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC) z
11.B.rehole diameter:i Program,1636 MSC,Raleigh,NC 27 699-1 63 6
12.V}',•:ll construction method: AlR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.al I er,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR;PATER SUPPLY WELLS ONLY: -..1
24d.For Water Wells producing over 100,000 GPD: Copy to P.WR,CCPCUA
1 -.';field(gpm) s 3 Method of test: /V) o11r Permit Program,1611 MSC,Ra...lgh,NC 27699-1611 ,,r) c
Z DATE SITE VISITED: /- - 1 type:�'i, f� Amount: O[ isinfectioo
VISITED BY: 093 w
c-_r i:11r 1 ATneH.r'•.,...Iin T inn..t..,n.,•.fnn • nm.nlal finolihr-rT;,rieinn of 117,tg,17 nen„rnne o...:r..i a a')nl a