GW1--06238_Well Construction - GW1_20230925

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° � S I 'UCT'[10 RECORD(in-v-a), For Internal'Use Only: ''; .
'lrLi7;li, C�l??s'�T
ifl Weil .olattrai for it orraiation: i ,
} - " q �; .. 14.WATER ZONES ,
'lam - - -- - ,FROM TO DESCRIPTION �f
Well Contractor a ft, ft 1 1 �/' ((, /�}�Pr�
. 33 3 -
V4a5-/ ft. ft I r
NC W Contractor Certi5eationNumber - V . 15.OUTER CASING(for Multi-cased melts)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS ] MATERIAL
YADKIN WELL COMPANY,INC. ft it • in.
i Company Name g�� 16.INNER CASING OR TUBING(geothermal closed-loop) �
®g 1� (4) • FROM TO _ DIAMETER THICICNESS MATERIAL �•
2.WellConstructionPermit#: �[ ft
]] m. q �(f�j
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc_) ,? ! /o I9f sP�Nl
ft ft. in.
3.Well Use(check well use):
17.5CREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICICNIHH MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) €Residential Water Supply(single) ft. ft. in. ,,-171.
y-
❑Industrial/Commercial ❑-Residential Water Supply(shared) 18.GROUT ='`•
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MG'!_iOD&AMOUNT
Non-Water Supply Well: 0 ft. 33 ft. brIchitc
Vynot4 .,'2G
1.3c6 `R
❑Monitoring DRecovery ft. ft.
Injection Well: . ':_ziki
ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODt.-
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain she,de.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under###21Remarks) ft f5Q ft / .
_ 4.Date Well(s)Completed: fi'Pt- Well ID# `9-xe 7 Y ft- PO ft- IA-
5a.Well Location: ; Phone # 70't - f? o '"'v f'• 1(D t1Wi- ' ""etdllq' mmo1
A-Ptetrea frny evj i1x2 ft. 333 ft , f g gr iSPO P
Facility (if applicable) ft. ft. ,
Factliiy/OwneName� ID# PP )
ft ft.
ft ft. `°'' F '
....-
Physical A dress,City,and zip - t'----t,►.e a _,,�fi :
ItPk.e s 21.REMARKS
County Parcel Identification No.(PIN) SEP w 5 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: inhtr",.l•it--) :3' '�t'r::r; UG..
(ifwell field,one lat/longis sufficient) 22.Certification: Dr'C7g Z'=
3C /40P33 N FP ,3,47.2S/ w '6'-ll-3
Signature erlacefilell Contractor Date
6.Is(are)the well(s):ARermanent or ❑Temporary.
By signingthisfonn,I hereby cert that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *.4o 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out!mown well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 1121 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 GW--is needed. Indicate TOTAL NUMBER of wells di'See Over'in Remarks Box).You may also attach additional pages if necessary.
'= _ drilled: 24.SUBMITTAL INSTRUCTIONS
9:Total well depth below land surface: 3.3 (ft). Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2©100)
-...iJV (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below..top of casing:,.. - Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" a� :{
` 24b.For Injection Wells: to DWR,Underground Injection Control C
11.Borehole diameter:'_ fP (m) Bit Off: 7 Copy 1 )
;�• Program,1636MSC,Raleigh,NC�27699-1636
12:Well construction method: AIR ROTARY:
auger,rotary,Cable, push;etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.• ,';, i ., county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY; •-r;. 24d.For Water Wells producing over 100,000 GPD:Copy to DWR;CCPCUA
I " / Permit Program,1611 MSC,Raleigh;NC 27699-1611 j
13a.Yield(gpm) - , Method'of test: Qe Y t
7D%HTH 1 OZ DATE SITE VISITED: J c13 .EC
13b.Disinfection type:_ _ Amount �: _-t"PA V to
al VISITED BY:�� 1
RTicP� 44
v,,,,,,�W-r 4 _ . al Quality-Division of Water Resources Revised 6.6-2018 • ;'