GW1--06232_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wel;Contractor Information: 0
Coy pertics 14.'WATER ZONES +
Well Contractor Name FROM TO, DFSCRIPTION
cal ft. GIr ft' kulti. b l �Pt5,1' aN G,71 ow---
NC Well Contactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name l'
°i� 16.lNN ER CASING OR TUBING(geothermal closed-loop) - tA
2.Well Construction Permit#: 3K� ` FROM TO DIAMETER TBICICtESS _MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. /93 f. to r$ in. , j$i' A�y`ti 7Z�
3.Well Use(check well use): '¢ c ft. ft. in.
1 Well: 17.SCREEN .,
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. _
t
❑Geothermal(Heating/Cooling Supply) )4esidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
`
Non-Water Supply Well: 1
V 7y ft 10 ft. ¢l OAKS 9 V1�1) f�ke5
❑Monitoring ❑Recovery ft. °� ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Test • ❑Stormwater Drainage ft. ft
❑Experimental Technology OSubsidence Control ft- ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DIULLINGLOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVroektype,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft ft. I.9 II'
4.Date Well Completed: 723 Well ID# Pr `6Li0 ft IcS 1 ft. i NI,d /�60
5a.Well Location: Phone # 3 O5 go4V-poi?/ (() ft. ` ft -c61,- r&Y Q
R deh kl ap er • ft. ft rte•.
Facility/Owner Name Facility MA(if applicable) ft. ft. '~C'•-''l./ v E
a
Z.-o A g Poe. b (4y 10 e c -Gapft. ft. SEP ? ; 202
Physical Address,City, d zip �p c t r' ft. ft 3
1414t/L4.V1.3 21.REMARKS iRt�r 7'�{ •n. �'...-f-741: r,i)
6
County Parcel Identification No.(PlN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ,/� �,+ 22.Certification'
3' 13+ 133[ N d I Q g,f1 Y O W 6-023-.2 3
6.Is(are)the well(s): • ermanent or OTemporaryature ed ell Contractor Date
j'P
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: ❑Yes or j To 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#21 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 3W-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlo Box).You may also attach additional pages if necessary.
drilled: [ 24.SUBMITTAL INSTRUCTIONS �
9.Total well depth below land surface: Prty� (ft.) 6'°
For multiple wells list all depths if different(example-3Q200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
at, 24a. For All Wells: Original form to Division of Water Resources (DWR), I
10.Static water level below top of casing: (ft.) Information Processing Unit, MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+"
11.Borehole diameter- !O (in.) Bit Off: 119e346 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) 8
.- Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY C
(i.e.,au ie,rotary,cable,direct push,etc.) 24c.For Water Supply and Open;Logp Geothermal Return Wells:Copy to the .
county environmental health department of the county where installed 15
FOR WATER SUPPLY WELLS ONLY: -24d.For Water Wells producing over 100,000 GPD:Copy to DWR CC9PCJs0
( Permit Program,1611 MSC,Raleigh,NC 27699-1611 _%�4..Uk 4 a;e)`1
13a.Yield(gpm) Method of test: QL ✓ ,
70%.HTH OZ DATE SITE VISITED: / "!v 3 /�'� •
13b.Disinfection type: Amount: '/
Psi VISITED BY: !/ ak•ekl• j
r......wr_il innmenhl fl....l:,.. r.:.:_:___r..,_._ ___ - Revised 6-6 2018 `I_ )