GW1--06983_Well Construction - GW1_20231027

° WJLL CONSTRUCTION ,CO if G W-1) For Internal Use Only: Q
•
--.-'7,-WI Contractor Information: ....,
O. ®a Li t; .1:IC 19.WATER ZONES IRI FROM _ TO DESCPTION
Well Contractor�N e ®�®It !.,7 ' 0 I treAA.44 77' KecK 3
c`� 7?-4 ft. ft I
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased wells)ORLINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO TDIAMETERin. THICKNESS MATERIAI,
- ft, ft. cl
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 1 5 4 qi 3' FROM TO DIAMETER THICIG RSS MATERIAL \
List all applicable well construction perm,s(i.e.UIC,County,State,Variance,etc) tki ' d ft °()5 m. d2-, s PPc.
3.Well Use(check well use): ft' ft. in. r. O
Water Supply Well: 17.F1ROM SCREEN TO DIAMETER SLOT SIZE TRIMNESS MATERIAL CI
❑Agricultnral ❑Municipal/Public ft. ft. in. s tv,.
❑Geothermal(Heating/Cooling Supply) fl3p.esiclential Water Supply(single) • ft ft. in.
❑Industrial/Commercial - DResidential Water Supply(shared) 1B.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 3 ' ft. y k®ir pOufied
❑Monitoring ❑Recovery 3 ft 67-i4° ft. Aril-Siam Ig ed tW ee/
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ,MATERIAL EV7PLACEMENTMETHOD %
❑Aquifer Test ❑Stonuwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. it ��,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Coolin turn) DOther(explain under#21 Remarks), FROM TO DESCRIPTION(color,hordnets,mO/reckrypc groin size,cte]
S° 4eg JiP- �5 Oft' SO' ft' `'OR
4.Date Well(s)Completed: ` 45 0® '� e11ID#('�P- ?
9 9 9 " ft ,- l ( ,5044 F/e e-/
5a.Well Location: (� Phone# '70 -677--3.24 /
2va'rlcC 12.0A ifik." ft ft 1
Faerfity/OwnerName Facility M#(if applicable) ft ft
j,D/ 76 V' 86%4- pig °`'►�
a Cvz it. � ..�ti:: f " �
Physical Address,City,and Zip aq'u'tO ft ft. OCT
2 .LflU"3
let let J4( - 21.REMARKS
County tt M� Parcel Identification No.(PIN) IfIs t,tr lh;`.it i'at\--:;*.7;+:s':q Cr.i
DWCiS,...
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long KZ
sufficient) �+ �a 22.Certification: '
34 33a48 ® N P6/ J7ta Sig). W - 4-d7 r9 3
6.Is(are)the well(s): I)1Permanent or ❑Temporary Sign fC Well Contractor Date
By signing this form,I hereby certi9 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IItNo 15A NCAC 02C.0100 or 15A WCAC 02C.0200 Well Construction Standards and that a copy
If this is a,repair,fill out known well construction information and explain tile nature of the ofrhis 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: r
B.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 5
construction,only 1 G1-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlm Box).You may also attach additional pages if necessary. 4
drilled: 6 24.SUBMITTAL INSTRUCTIONS'-:%
9.Total well depth below land surface: q2 ( t) Submit this GW-1 within 30 dais of well completion per the following: CK
For multiple wells list all depths IIfdlferent(example-3 c@200'and 2@i00)
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
Ifwater level Is above casing,use"+"
11.Borehole diameter: 6 (in,) Bit Off: 4` ,r(ac 24b.For Injection Wells: Copy to DWR,Underground Injection Control (I(JC)
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 C
di ir Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ` U
70%HTH OZ DATE SITE VISITED: ! ®,
13b.Disinfection type: Amount: i'. f .
-_�.- - " VISITED BY: U
,ina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018