GW1--07529_Well Construction - GW1_20231120

''-rlr CONSTRUCTION +tCO TB('GPI-1) For Internal Use Only:
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I.Well Contractor Information: `11
3 a} 1-6. i\ 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
Ig �`
LI��d^� )e ft �� � ft. S�$e�" ��'t��' ��J�'�`q, �'►/d�3 �tr"' ,�
ft.
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NC Well Contractor Certification Number
15,O R CAS/N (for multi-caied wells)OR INER(if a licable)
YADKIN WELL COMPANY,INC. FROM TO - DIAMETERTHI 55 MATIAL
ft. 7ft. m,
Company Name l
�,,C a I`� 16.D ER CASING OR TUBING geothermal d sail-loop)
2.Well Construction Permit#: i"t 3 ✓ [ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i,e.UIC, ounty,State,Variance,etc.) ft. 3 ft m. (� j���
'�' I �� �°��� O� �r PAL
3.Well Use(check well use): ?T 1 ft. / in. f 1
Water Supply Well: 17.SCREEN
N
FROM TO DIA SLOT SIZE TSI ,SS MATERIAL
❑Agricultural DMunicipal/Public /ct. in.
❑Geothennal(Heating/Cooling Supply) Residential Water Supply(single) • ft, ft. in. /
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ail ft, 11 cii c 1 fi 9 4S s /t)41g
❑Monitoring ❑Recovery t it ftft:
. /
Injection Well:
:Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC
K(fappticable) •
.
❑A uifer Storage and Recovery ❑Salmity Barrier
FROM TO MATERIAL EIIIPLACEMENT METHOD
• ❑Aquifer Test ❑Stormwater Drainage ft. ft-
DExperimental Technology ❑Subsidence Control ft. it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,oaWrorktyac,grain size,etc)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) o ft _ ft 5011
4.Date Well(s)Completed: (Q s 20-2 3 /A- Well ID# P-'4 9 8 3 a ft o-ft 1 t 14 5, � L. r .,4
5a:WellLocation: Phone # /7-(.56,'-)., 1 gei 1409-ft. IT if 4 t- 51 1K- -
ft. ft
if e4 Ate ?, �1� Kak -, T-- _-
Facility/OwnerName Facility lD#(if afplicable) ft. ft. ' -' ,k,'•, L, i�,.
' :i,-c$,v .' i^..:'
6-r eif s /Diied 3, 1( ft. ft. NOV 2 9 2023
Physical Address,City,afd Zip d ;� .-
A--k e, �S 21.REMARKS irsm;- ., ,-. .. ,"•. ":rr I(r-
County Parcel ldenth5cationNo.(PIN) 9061t' tom'nele 4,Bud ,, 1 $ 1n ig"'"zi if ilto44,6, . - ..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --C We6^'44,- O4,1- it-4 S Chu....". L#n a J .la-
(ifwell field,one lat/longis sufficient) 22.Certification'
3 c a. ,i.-7.190 ,N $ 1 304 � 7G6- W
6.Is(are)the well(s):XIPermanent or ❑Temporary Signature o ed ell Contractor Date
By signing this form,I hereby cei•t(fythat the well(s)was(were)constructed in accordance with
rS-
' 7.Is this,a repair to an existing well: ❑Yes or id(I'o 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction,Stondards and that a copy
If this is a repair,fill out kno)m well construction information and explain the nature of the %of this record has been provided to the well owner.
repair imder#21 remarks section or on the back of this form. Cs
.1,23:^Site diagram or additional well details: CM
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-is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: f 24.SUBMPITAL INSTRUCTIONS
9.Total well depth below land surface: Po a3 (ft') Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ifd�erent(example-3(12 0'and 2@100')
Isla. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: d9t (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+' •
11.Borehole diameter: (in:)µ
r 'rBit Off:,,2,?51 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
,.,-:
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction methdd: 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 03
FOR WATER SUPPLY yVET.T S ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA t
Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611 (}�
13a.Xield`(gpm) t �b ,,,,
` 70%HTH Amount: 3 6- OZ DATE SITE,UISITED: /`/z _c.,3
13b.Disinfection type:_
i
Revised 6-6-2018 .