GW1--06853_Well Construction - GW1_20231030

'WELL CONSTRUCTION RECORD(GW-1' For Internal Use Only:
1.Well Contractor It ration: .
- (4-.)2 C`8/r " 14.WATER ZONES I
Well Contractor Name i• 1"").1"").' FROM TO DESCRIPTION
3�.3�'- 1 OC)ft' 50 a• �S 6 let"-
ft ft
NC Well Contractor Certification Number 15.OUTER CASING•(for multi-cased wells)OR LINER(if ap [cable)
YADKIN WELL COMPANY,INC. • FROM TO _DIAMETER THICIOVESS MATERIAL.
ft. ft. • in.
Company Name 1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: (9tP 7 3 W FROM TO DIAMETER THICKNESS MA �+
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 41
ft lq it�s%s in. 50-a, C.._
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipaI/Public ft. ft. 'in.
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) • f. ft. in.
DIndustrial/Commercial _ (❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMILMEMENTMET OD&AMD
Non-Water Supply Well: 0 ft. Q5' ft L/1✓Y CA sk a IL ®f
OMonitoring ❑Recovery ft. ft. /5'� S 51)14 1D
Injection Well: ft. ft. L o
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑Stonnwater Drainage ft. $•
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothe al(Heating Co gRetum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPITON color,hardness;s Wrack type,gra/ia size,eta)
4 ft.
erra 4 6 f ft 5-0,./ floc A , /,ii ii 4. ::ify.e...
4.Date We (s)Completed: W cf{!T], 'ellID#Atli l✓7 z 71 t ./ t•-ea , .
�-r - o, / s
Se Well Location: Phone # 33. - -53�.3 7I ft 16e ft Gs�o-“,fen c-e-Yr'i,j 'k ( Cam'
• R1:L -f -7lQve- . 00 t-) ft C." ft 6 044Ite/ 44-71-4-3(l Yit) ,
Facility/OwnerName FacilityID#(if applicable) ft ft
G.o/3E( Dm a tn-r r '1� cz.vzor ft. ft. , ,, s::':;+ a. .��,
Physical Address,City,and Zip ��� '�C � 2x.REMARKS
ft. � (1('T 3 9 2623.- .
County Parcel ldeentitication No.(PIN) `'' _
'4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) iq.nauon:q I s a� N -f -I3 32 ?- " 546 � �
6atn bf Certified Well Contractor Data
6.Is(are)the well(s): ermanent or ❑Temporary , •
igning thisform,I hereby cerlibo that the well(s)was(were)constructed in accordance with
7.Is this a repair to au existing well: ❑Yes or To 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well mullet
repair under 21 remarks section or on the buck ofthisform.
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-1 i l needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlo Box).You may also attach additional pages ifnecessary.
drilled: l 9� 24.S17BMTITAL INSTRUCTIONS
9.Total well depth below land surface: �. (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdifferent(example-3(Q200'"and2Q100)
10.Static water level below top of casing: 5b 24a. For All Wells: Original form to Division of Water Resources (DWR),
(£t) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: tP (in.) Bit Off:‘I ®7 C) 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 producingoer 100,000
/'� i Permit Program,1611 MSC,Raleih,NC 27699-1611 Copy to DWR,CCPCUA
13a.Yield(gpm) )� Gl/i Method of test: " Q
eif
13b.Disinfection type: 70%HTH Amount• 1 OZ DATE $ 1 VISITED:l d ,-.7 ` z-z
f - \ lea :
trd`da, tar _!_