GW1--06057_Well Construction - GW1_20230921

'WELL CONSTRUCTION RECORD(G1V-4) For Internal Use Only:
I.Well Contractor Inforruntion: _
.3t a 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Nails 7' fk 31-. ft• ! ye�
. 57 A �� fit. ' I .
it. ,� �t��,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casr?`d wells)OR LINER(if a ticable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name �1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 )5 4° 3S FROM TO DIAMETER _THICICNESs MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,eta) 41 fit lit ft. iv.ys-0 ID. . 1a il/
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural OMunicipal/Public ft. ft. in. 0
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑lrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan:Water Supply Well:
0 ft. " f• eati-Ill h3 pee
OMonitoring ❑Recovery 3 ft. a6 ft. Oen„stwirl
roti5t.,ed
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEIENTMETHOD
❑Aquifer Test • ❑Stormwater Drainage f' ft.
❑Experimental Technology OSubsidence Control ft it
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilkoek type,Asaiu size,etc.)
DGeothermal(Heating/Cooling Realm) ❑Other(explain under421 Remarks) soli
s e+ oV>15 3
4.Date Well(s)Completed: •I S i 0 Well TON AA�5 6 4/ s1$ ft. 3q): ft et,d)PJ G"'r41Awn
qr
5a.Well LocationC-A a/J+) Phone # QSO- 1?_7L LID ft. ft
ft. ft.
�,tt,,,�,,, --.1 ft. ft.4 fie-an 1
/'O
FacilitylOv+nta ` �
� �a Facility ID#(if applicable) y.a r-• ,•e -r..•. _ _.
Z afl b4,k McG131 N.."E:n e b.L.,s
Physical Address,City,and Zip ft. it. C[L P d 1 L O L J
21.REMARKS
-s
County Parcel Identification No.(PIN)
GWL:r'a0;..;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 &h'7 rail N sl ca ,ny6a w /s.SP_)-e-i.3
Signs
6.Is(are)the well(s): permanent or ❑Temporary
a of ' ed Well Contractor Date
By signing this fonn,I hereby cert fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Alio 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this 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 i21 remarks section or on the back of this form. 23.Site diagram or additional well details:
B.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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 741
1 (fit') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3(4)200'and 2©100�
° 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /IOC (fit•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaler level is above casing,use"+" 4.012,11.Borehole diameter: it, (in.) Bit Off: 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
�I / Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(rpm) E. Method of test: W I V ( 0-.23 a
13b.Disinfection type:
J
70%HTH Amount: /1 40 OZ DATE SITE VISITED: / Z 3 t
/� t3
r ISITED BY: (/f
Pri GW ' i
Form GW-1 I --- ounces Revised 6-6-2018
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