GW1--06237_Well Construction - GW1_20230925

t ' 3 1
r J @ CONSTRUCTION I'CO (GW-1) • . For Internal Use Only: "
I.Well Contractor In motion:y
,oet ' 6
. . .
" ' ' 19,WATER e=.ONEs
FROM TO • DESCRIPTION
Well Contractor Name "� J g ft. 7s ft Attby 0 gee s bgo G'rC�
H_ r -S-I ow ft. l.1 it d !
NC Well Contractor CertificationCertifcation Number 15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft ft. i ' in.
Company Name r,
, 16.INNER CASING OR TUBING(geothermal closed-loop)
���� FROM TO DIAMETER THICKNESS MATERIAL M
2istall Construction Permit#: ft �� ft, L yg in. ��8� Girl i'
List all applicable well construction permits(i.e.LAC,County,State,Variance,etc.) i 5 99 T--,.
ft ft. in
3.Well Use(check well use): 1
17.SCREEN ..,..
Water Supply Well: mom TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
OGeothermal(Heating/Cooling Supply) Sesidential Water Supply(single) ft. ft. hi.
❑lndustrial/Commercial . ❑Residential Water Supply(shared) 15.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (J/c� ft a'Q ft. tiair(� C� I`� W ao Ettq
OMonitoring ❑Recovery ft. ft. Fs�_r t. i....-^,�....
Injection Well: ft. ft:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) F D
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ES EtY
❑Aquifer Test ❑Stormwater Drainage ft. It.
In brra irin ar �,,x;.,," l t'-
❑Experimental Technology ❑Subsidence Control ft ft. DWL r1
0 Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rocktype,('rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under /21 Remarks) aft. it3 ft. 16.;i
4.Date Well(s)Completed: _vim' Well mi A jO- i3 O ft ft ,sdf . tAJlo4\@t4 Coc
5a.Well Location: Phone # gi 3-11 5'171 76
v3 ft )31-f- M !IN130 K3hili-y grew-K
5. 7 etie pvang Srette ,a it.1 199 ft, ZDft `; y
Facility/Owner Name Facility ID-4(if applicable) aa® ft"- ft (50F 1 14 styC®J�/
Ai. ) l t6ktioa, s f Td fly goo A eie �$a f. 642 . col -}- 1`d ir}./T�,Y grans
Physical Address,City,and Zip I' C Vaz `i
F 21.REMARUCS
�� / @ r County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
36-0f01t t3 N-9/,231cAillo w2egi-/-4:5=___ 5 -23
6.Is(are)the well(s):AP ermanent or OTemporary
Signature of Certified Well Contractor Date
By signing this form,I hereby cent(that the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or AfTo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a ropy
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 under1i21 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 I GW-)is,needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '- " •519" (ft.)
• For multiple wells list all depths If different(example-3 r©200'and2@100') Submit this GW-1 within 30 days,of well completion per the following:
10.Static water level below top of casing: • - 190 - (ft.) 24a. For All Wells: Original foim to Division of Water Resources (DWR),
Ifwater levelis above casing,use"+" 7
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: .. (in.) Bit Off' 5 Pe& - 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
Program;1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
AIR ROTARY 24c.For Water Supply and Open-!Loop Geothermal Return Wells:Copy to the 6
(i:.e 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 7rr
] r t Permit Program.,1611 MSC,Raleigh,'over
100 0 9-1611 • t
13a.Yield(gpm) f•J Method of test: a I
70%HTH � OZ DATE SITE VISITED: /"3". 3 ,s-h9
13b.Disinfection type:-- . Amount ivr 1
. I" q
";. VISITED BYt V,�. ,:.:, (�, �, d
FormGW- _ • - •onmental,Quality-Division of Water Resources Al 5 Revised6-6-2018