GW1--06214_Well Construction - GW1_20230925

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well ontractorinformation:a. -I 4v Silo kir,/ 14.WATER ZONES 1 /
Well Contactor Name
FROM TO DESCRIPTION , 0(�J,2o 5
Jo 6 ft .7v7 ft'
.3d 3 �O� Or
�� - ,?7� - y�
r7ir. �� ft 36a , 37a •- 7
NC Well Contractor Certification Number 15.OUTER.CASING(for multi-cased wells)OR LINER(if ap livable)
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER THICKNESS 1 MATERIAL
7. ft. ft. in.
• Company Name ry 16.MET/CASING OR TUBA(geothermal d ed6 loop)
2.Well Construction Permit#:0 I 0a - C v 0 ®&ro. FROM TO 1 DIAMETER THICICNESS MATERIAL Q'
List all applicable well construction permits(Le.U1C,County,State,Variance,etc) ±e2 ft 70 ft {,-j,, in. S fj
. ' L7© /ct& (`/fed
3.Well Use(check well use): ft ft. [] ; in. // d
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Z
❑°.gricultural Olk umicipa]/Public f Mtn in.
' / "
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. � �
fr.
❑Industrial/Cornnlercial . DResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT (o
Non-Water Supply Well: ® ft. �' ft. Pm& 8 I -
❑Monitoring ❑Recovery • I ft 70 ft. Alta
Ce, v PJ J
Injection Well: , ✓�
DAquifer Recharge t ..,_+.,,,r 1... ''. LiGroundwaterRemediation 19,5A1VDlGRAVELPACK(iiapplirable) CA)
❑Aquifer Storage and RecC Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Test S I 2 �� Stormwater Drainage ft. ft. '
❑Experimental Technplggy <•a,,1 t'�f-;a 13SriblEc ence Control ft it ✓
❑Geothermal(Closed Loop) l + ❑Tracer 20.DRILLING LOG-(attach additional sheets if necessary)
FROM TO DESCRIPTION(valor,hardness.soil/rocktype,grain size,etc.)
❑Geothermal(Heating/CooingReturn) ❑Other(explain under#21Remarks)
JA,44. ifAr2 e1/2.3 f�/� ® ft. 4. 0 ft" S® / . _5; G0ap1
Ait1 4.Date Well(s)Completed: £1/g•7/e3 WellID#AA{- C.30 ‘C) ft. /rev ft- 1-4 .1 6.,cn)h.,
Iso-( 63 5a.Weil Location: Phone #.33 - ?2... if 0 '
f0t 31f) f SS w ,e.lu�S
• cea,` 0.4g F i, 65e . az1.4.Cl dV ft. tioft / (,,-,...1i* , Z.
Facility/OwnerName Facility DWI(if applicable) ft. ft <
A) Ck 1- S GP e tr1"t9 7Q6"e0) ft. ft #
Physical Address,City,and Zip ft ft. .Ir
f.A f A LP.1111 21.RFMARxs Q
County Parcel Identification No.(PIN) C Xa OM J),j/�P4,( Of 741611r ",)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Br
(if well field,one let/long is sufficient) ® s 22.Certification: • 4
�c �� t I®''1 N �6 t��-il W • ,2'7
93
6.Is(are)the well(s): @Permanent or OTemporary Si atnre of Certified Well Contractor D e GI
�
By signing thisform,I hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or OlVo ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#t21 remarks section or on the back of this form.
23.Site diagram or additional welI,details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bank of this page to provide additional well construction info
construction,only 1 GW is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: • �iJ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ®'� (ft) Submit this GW-1 within 30 days o£well completion per the following:
For multiple wells list all depths Ifd Brent(example-3 a@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5tatic water level below top of easing: v (ft.) Information Processing Unit, MSC,C,Raleigh,NC 27699-1617
Ifwater level is above casing use"+'
11.Borehole diameter (in.) Bit Off: 7, gzs 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
I
FOR WATER SUPPLY WELLS ONLY: /�� 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
��trec Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: �� `1g4-
13b.Disinfection type: 70%HTH Amount:S2: OZ DATE SITE VISITED: ,
Pr9 rtP
VISITED BY: fs ,lb'Z ill ii-
Form GW-1 tunental Quality-Division of Water Resources Revised 6-6 20I8