GW1--00765_Well Construction - GW1_20240131

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"sa l 1iL CONSTRUCTION:RJ:RECORD ICWiV-a) For Internal Use Only: •
I.Well Contractor Information:
Jdelti n11h ' _ 14.WATER ZONES I
tl! ./
Well Contractor Nam2 FROM// _ TO11 DESCRIPTION
�� ft. it.I/i7iP ft, ® ft. X).._ So t� 5i�O/J Aurie P cF
1��s -
NC Well Contractor Certification Number 15.OUTER CASING(far multi-rased wells)OR LINER(if a licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL _
ft ft. in.
Company Name G 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 0 4 'ZJ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) 4. 1 ft' �61 ft 6,.1;-.5 `W ,
in S°A� p vc-
ft. ft. [G in. d
3.Well Use(check well use):
17.SCREEN
Water Supply Well:
pp Y FROM TO DIAMETER SLOT SIZE TmCICNESs MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) pe2esidential Water Supply(single) ft. ft. in. '
❑Industrial/Cornmercial . ❑Residential Water Supply(shared) 18.GROUT
❑Ini ation "'i_, T: %' 7Wellsl>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:'-`,w'r-is s--- bit q>' it. 13,41-ektigs t Y,ri
❑Monitoring t 1 `ARecovery ft. 6✓r ft. u rei
d
Injection Well: ft, ft,
❑Aquifer Recharge -, -,) ;s.•.13Gr'otibdwater Remediation 19.SAND/GRAVEL PACK(if applicable)
tt Cif;-_:III t ., ice(
❑Aquifer Storage and Recover;a Os a❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. it.
' OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
•tt''df'' Id--iti d®,'3 /� Dft. r� ft wait/
4.Date Well(s)Completed:Or�'ao'''a0 Well ID#44P' 657 G 5 'ft 7(S ft" /4pei,re Li
5a.Well Location: /� Phone # $r0a T/ 95' i?, f
ft. ®®� a' s t��4/�...4 `y' �G���e'� ..:''
®L4eS / 4.i'1la 1)0 t. 60e ft i'1d?e1-55P ba1ce
' acuity/Owner Name Facility ID#(if applicable) bav ft. (?eft.Yt, ,e. e4;41 z� -, 2/i'Valrolu
, f�3 r ev,e s Chest-Awl MIS/ ft' . ft. 7L.,A 2) lL '
Physical Address,City,an Zip ip r `„vor ft. ft.
40 21. • ..
County / Q s Parcel Identification No.(FIN) /`/ //7e` X1r if f'kid '&
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/longis sufficient) oe • 22.Certification: E S 3�i'u�3 v
2 f Ss, 29.ZL p N f}� `4 Sf'7U w
6.Is(are)the well(s): itermaneat or OTemporary Sip(c2411).14,-Zi e of C ed Well Contractor . Date RN 8
By signing thisform,I hereby certij5ithat the well(s)was(were)constructed in accordance with
7.Is this a repaiit to an existing well: DYes or J4No I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional-well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 isyeeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /3b$' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd(fferent(example-401200'and 2©100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: �C� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'
11.Borehole diameter: !O (in.) Bit Off: l_®6 24b:For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
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
a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) h Method of test: Qp‘r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
70%HTH oz DATE SITE VISITED: �'4 2 3
� j
Uri .P
VISITED BY: 01
Form GW-1 onmental Quality-Division of Water Resources Revised 6-6-2018