GW1--06865_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
- • Ui Q�k e4 S 19.WATER ZONES I
Well Contractor Name FROM TO _DESCRIPTION
J�r9 ft ar ft. i GPnn
ft. St
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
YADKIN WELL COMPANY,INC. FROM TO _DIAMETER THICKNESS MATERIAL
ft, ft. I ; in.
Company Name
16.DINER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit it: )'3 Lit-vi n FROM TO DIAMETER TffiCICNESS MATERIAL _
List all applicable well construction permits(1,e.UIC,County,State,Variance,etc.) 4.1 ft. I I ft G A/ in. so eat Pv e
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)'•' • ft. ft. Iin.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETSOD&AMOUNT
Non-Water Supply Well: 6 ' a ' Wok pf v5 Poured 4 ix
❑Monitoring ❑Recovery ft. ft. ©vt�1C
Injection Well: 4 ft. 30 • Great Pvrivra I. 6s3
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILIING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(mbar,Lar•dness,soil/rock type,grain sae,etc-)
❑Geothermal(Heating/Cooling Reiman) ❑other(explain under#21 Remancs)
p 6 ". its ft. 5011
4.Date Well(s)Completed: 13'3 Well ID#A4 f•-- 41 g if/y ft' 4121 ft' 6 rov
5a.Well Location: i-i etsi iir Phone # Q-779- t1.3 ft. ft _ _ __
G^ae,pd ft. ft. , •",
Faollity/OwnerName Facility ID#(if applicable) ft• ft. ' c
1 D4 3 13�a Oo cQ ,�e^>✓� ,, ft. it C l 0 2023
Physical Address,City,and Zip u C. a mil.[1 cis it ft. I ri C r -c4 n P,; ,7)-,-I t I,-
41: 21.REMARIZS C;'•.•`.`:`: t: V
County Nicol Identification No.(FIN)
. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
36 lie, Iz'93 N $1 34, .5'3'T W w . . lbll l(23
roil'ermanent or ❑Tom or Sigma of C ed Well Contractor Date
6.Is(are)the well(s) m p ary
By signing thisform,I hereby certjfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: .❑Yes or PO 1SA NCAC 02C.0100 or 15A NCAC 02C.0200:Well Construction Standards and that a copy
Ifthis Lea repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the cell owner.
repair under#21 remarks section or on the bock of thisfonn. •
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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in RemarIa Box).Yon may also attach additional pages if necessary.
drilled: l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a-I" (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@i00')
( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5taticwater level below top of casing: �� ft. Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
11.Borehole diameter: 6 (in.) Bit Off: r9 eq 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IIJC)
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
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin(;iover 100,000 GPD: Copy to D�CCP. UA
1 e _ Permit Program,1611 MSC,Raleigh,NC 27699-1611 e_e C
13a.Yield(gpm) Method of test: ai/ e /
13b.Disinfection type: 70a/o HTH - Amount: ILO OZ DATE SITE VISITED: pd �^J're`L-2' b"4' CI P''
VISITED BY: V /u / /
,.u' rtmen l,
tofEnvironmentalQuality-DivisinnofWaiRecnurces Revised6-62018`. i