GW1--06977_Well Construction - GW1_20231027

.1 .'1(TCTJION RECORD(GW-1) For Internal Use Only: 11- ,
Contractor Information:
e43.
19.WATER ZONES I CD
Well Contractor Name FROM TO _DESCRIPTION Cr
i t 51t q 6,7s` ft. �.S'A ,1" ' ro
fi '� ft, ft I 1_
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap Licable)
6...
YADKIN WELL COMPANY,INC. PROM TO _DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name
r �+ q 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: L / 1 ,�, FROM To -DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i,e.UIC,County,State,Variance,eta) Pit 1 Q lit, 6,,i)en. i�,rox v® ?
3.Well Use(checkwell use): ft' ft. 1n.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL, 1
❑Agricultural ❑Municipal/Public it. ft. in:
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) • ft ft. in.
❑lndustiial/Commercial . DResidential Water Supply(shared) 18.GROUT
❑lIrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ° ft 411-Aim Fovre4
❑Monitoring ❑Recovery q'it ,27 °ft.
Injection Welke-`�� �� e��'el
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storrnwater Drainage ft. ft
DExperimental Technology ❑Subsidence Control ft. - ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,etc.)
OGeothermal(Heating/Cooi ngRettun) ❑Other(explain under#21 Remarks)$+ ,
f �3° 0 ft �ed V y - 0 Oddft' SOH
�r
4.Date Well(s)Completed: q,140 Well ID#A,�f_ le ! 5 /a R' lea°ft.. m 'df r,S® 21e2 .'oPe`6-1,.?
5a.Well Location: Phone# rlDV 47 7 -4Z9 ft. ft
•LL At' de ft• (/ be ti y`a b 60111410 f ft ft �^ �; - 8 ®
Faet7ity/OwnerName FaeihtyID#(if applicable) ft. ••t `•: -r•'L=.ri V L-_.L.
I o/ it S gam,,. eV05fif ft OCT 7 2023
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Physical Address,City,and Zip they CreeX p Nwp�t�4 Z ft ft.
tJ 21.REMARKS to <<-1,. ...a..: Cr.,.
All
•
Comity. /Lt'w'e Parcel Identification No.(PIN) . ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one let/long is sufficient) 22.Certification:
3.: • 33: g ii[a N 21 I,S. o,1 $® w /1•n JD-5
6.Is(are)the well(s): ermanent or OTemporary Sign f ertifie ell Contractor Date
By signing thisform,I hereby certify chat the well(s)was(were)constructed in accordance with 5
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 1SA NCACO2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information d explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
23.Site diagram or additional Well details: �O
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 2
a 4.SUBMITTAL INSTRUCTIONS CO
9.TotaI 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 If different(example-3©200'and 2©100)
° 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 C
Ifwater level Is above casing,use"+"
11.Borehole diameter: Cp (in.)
Bit Off: / _O 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC) Gr Program,1636 MSC,Raleigh,NC 27699-1636 °
AIR ROTARY
12.Well construction method: • N • 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 produci,g over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3�a2. Method of test: �atl/ Permit Program,1611 MSC,Raleigh,NC27699-I611
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13b.Disinfection type: 70%HTH Amount: 2.7 Oz DATE SITE VISITED: /of l-'.3 •
I � 1
VISITED BY: I/
arolina Debirtment of Envirnnroa dal h„arr,._n;.,;..;,,, fm,,o.n o..,.,,...o.. n a,aeaa g_s_lm a