GW1--06860_Well Construction - GW1_20231030

. IT%_l' CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
/_ 11 tie..lk 19.WATER ZONESWell ContractorNameV` FROM TO I DESCRn'TION �`7 45
/� *lea 1O( ft SO �- 1 13hP y w� r"' ftiiin
46 1U-/ 4yoft. S'o o ft p rh w FGc,a So#-f- ifor,
NC Well Contractor Certification Number f
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
YADKIN WELL COMPANY,INC. FROM O DIA R 'THICKNESS •NIATE$y
ft in.
Company Name Q'f� a rJ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 O f D /3 FROM TO , DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) y4-t ft"
a ft e�%� iu• �w®C�V-, G44Vsa-t-e-f
ft, ft. in. S 0
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipaUPublic f ft, in.:
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in. .
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation OWells>100,000 GPD FROM TO I. MATERIAL EMPL EMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. i1 ft. G(„1 b S ( , as(/ 5�'�,yr►1-'�1
OMonitoring ❑Recovery it. ft. f 1
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAM/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM O MATERIAL EMPLACEMENT METHOD R
❑Aquifer Test ❑Stormwater Drainage ft
'�❑Experimental Technology OSubsidence Control ft. /irO
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) O.
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain sae,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft r o ft• 561
1
4.Date Well(s)Completed: ' l 2 m
3 Well #Ate®-"9r ( 0 ft• l(i,0 ft• ( 0 pi i^ 6 h & h9
® E/ r
5a.Well Location: Phone # 7o y-21I .7e.S WO ft go (4f'Yt'L 9/'c.n,a4
31,cr. AA Co ft. tad ft. � y h j- G�r� l4ie�"h p l 0- 4;A)-
Facility/Owner Name Facility ID#(if applicable) ko ft. JQ 1 it 19 (h k r'e It-
C'fra,ta.Viet,h G-.1-+ Loth So E ft. ft
wv a 9-ft. -.0A ft. c c rm.. ��-�.7 M- 5iM- ,
Physical Address,City,and Zip min
J •
21.REMARKS b.
/��i�LS�,�t®O. '
County Parcel Identification No.(PIN)
•5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O C T 3 2023
(if well field,one lallongis sufficient) 22.Certification: Ill,:.:•,,; ,),
•
.16, dd°le•a et q o N g''1. C, . 201 w J C Z/ c.:°1_',:`y '3 cf.- 15-- 23
Is(are)the well(s): [Etgermanent or OTemporary Signature of Certified We Contractor Date
6.Is
( ) By signing thisform,I hereby cent fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: t7Yes or Ao 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If thisisa repair,fill out known well construction information and explain the nature of the ofihis 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 GW-1 is peeded. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ( o- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(0 2000'and 215100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5tatic water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use"+"
Bit Off: C.( S 0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
I w i Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) l Method of test: t
13b.Disinfection type: 70%HTH Amount: 9 OZ
DATE SITE VISITED: "®L e& C4C1`42# 4?ilvii, 1!
VISITED BY: De{'
pri cP_1
Form GW-1 enrol Quality-Division of Water Resources Revised 6-6-2018 s