GW1--06965_Well Construction - GW1_20241119

M CONSTRUCTION RECORD (G3W-1) For Internal Use Only:
1.Well Contractor Information:
�7 14.WATER ZONES
��CA,,
y �i FROM TO DESCRIPTION
Well Contractor Na
/?77 ft. 4;9 ft. if", ..I .73
NC Well Contractor Certification Number 15.OUTER CASING(for niulti-cased wells lORLINER(if ap licab]e)
YADKIN WELL COMPANY,INC. FROM TO • DIAMETER 1 THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 I ir7 vi FROM TO DIAMETER THICKNESS MATERIAL (A'
List all applicable well construction permits(i.e.VIC,County,State,Variance,eta) lit Pep ft 4.,3v
in. !/V flit/ _�
3.Well Use(check well use): ft. ft. m �'
Water Supply Well: 17.SCREEN t-•
FROM TO DIAMETER SLOT SIZE TmC1c NPSS MATERIAL 5
❑Agricultural ❑Municipal/Publio ft. ft. in.
• OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) • ft. ft. in.
❑IndustriallCommercial . Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 4 ft. 5�+,j�i� po,fed
--
❑Monitoring ' _ ; ❑R 6ecovery ft. p
ft. �J 0,2 Iufl.7 e enved
Injection Well: ft. ft.
❑A uifer Recharge i j LO14If1Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery `
q g ��l) DSalinityBarrier FROM TO MATERIAL EMPLACEItElTMETHOD
❑Aquifer Test ; :_, - - • ❑Stormwater Drainage ft. ft.
❑Experimental Technology ;_ ❑Subsidence Control ft. It.
❑Geothermal(Closed.Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soii/reektypq grain size,etc.)
OGeothennal(Heating/Cooling Retitrn)� er(explain under#21 Remarks) ® ft I./3
9ft. 6.11 j ®�CS
4.Date Well(s)Completed: Id' '�')'"f WelI ID# 4 'SQ R/ //.S'ft 3 )• ft V. 7 a . e
ft. ft. ......
5a.W/�Well Location: Phone#7®4062's iflo
`/ d I Ai; ft. ft C
kc i• Facility/OwnerN e �N5 Facility Mii(if applicable) ft ft.
Co et 1+� t LA "�i( e�'S ek, ft ft. ` 4
Physiial.L QC Address,City,and Zip \f
21.REMARKS
G 4`� e s .'7- 0? ° JZ'(AC (wry•ae' ia'vtJ /00 ypts
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification: .gA
3( /7 6"7,id/ N 9 f Ad IA04 .' W /®a '> ® y� 0
6.Is(are)the well(s): ermanent or OTemporary 5 re of C ed Well Contractor Date
By signing this form,I hereby certjfy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fro 15A 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 it21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/11PT 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 G-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: +
361 (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©I00D
o (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 Q
Ifwater level is above casing use"+"
(in•)
Bit Off_ (AP: 01 0 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IIJC)_.
11.Borehole diameter: 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 g
(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 Welts producing over 100,000 GPD: Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) 2 Method of test: ,' y -
13b.Disinfection type:
70%HTH Amount: /5 oz DATE SITE VISITED: G( ^ V
VISITED BY:
beoartment of Environmental Quality-Divisinn of Water Resources Revised 6-6-2018