_Well Construction - GW1_20230315 (55)

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,`,.-sv�llC•�.��,��F�TS 1JT�'1lJeCT�'�1�T��C�� ��P�-1 p For Internal Use Only:
h.;Well Contractor information:
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14.WATER ZONES
Well Contractor Name FROI\2 TO I DESCRIPTION
�,� bu7 ft. ft. , Pub C cWU-bl,
ft. ft.
NC Well Contractor CettificationNumber 15.OUTER CASING for niulti-rased wells)ORLIN
YADKIN WELL COMPANY,INC. FROM To n1Al1ZETSR THICCompany Name ft. ft., n16.R NER CASING OR TUBING( eotbermal close2.Well Construction Permit#: to w FROM TTffiCIList all applicable well construction permits(4e.EW,,County,Stake,Variance,etc) ft I�' ft in. 13.Well Use(checkwell use): ft. ft. in. '
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAT
❑Agricultural ❑Munioipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To WATER
AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 3�u ft.
❑Monitoring ORecovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft
19.SANDIGRAVEL PACK rfa livable)
❑Aquifer Storage and Recovery ❑SalinityBaairr FROM I To I 1%aTERT.sr. Ea CEMENTD=- OD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology OSubsidence Control fL ft
❑Geothermal(Closed Loop) ❑Traces 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Ret im) 00ther(explain under#21 Remarks) FROM xo DnCRIPTIOx color,hardness,soiVrack e .in sfre,etc
0 ft. 5 ft. sd '
4.Date Well(s)Completed: A 17--A-3 Well nw a o °.,S ft- '®aft
5a Well Location:
'IR06'
one 65Q
�� t "/Il o
ft. ft Name FaaMyM#, t
(if applicable) ft. f _
AM
Physical Address,City,and Zip �tI ft ft.
�illl7`�f 21.RF.riUPM _+ s- i
County Parcel Identification No.(PIN) -"
5b.Latitude and longitude in degrees/minutes/s6cands or decimal degrees:
(ifwellfield,one lattlongis sufficient) 22.Certification:
6.Is(are)the well(s): Permanent or ❑Temporary 5rgnatare of Certified We Contractor Date
By signing thisform,]hereby certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to au existing well: OYes or Wo I5ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction 2andards and that a copy
If this is o repair,fdl out known well construction information and explain the nature of the ofihis record has beer provided to the ti♦+el!owner
repair under#21 remarkr section oron the backofthiaform. 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlcs Box).You may also attach additional pages if necessary.
drilled:_ //pp� 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �lJ��i
For multiple wells list all depths lfdifferent(example-3 a(}200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
�®10.5tatie water level below top of casing: ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft•
Tfwater level is above casing use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 Q!
11.Borehole diameter- (in.) Bit Off:5 Sic 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) {�
Program,1636 MSC,Raleigh,NC 27699-1636 u
12.Well construction method: AIR ROTARY Ar
24c.For Water Supply and Open-Loop Geothermal Return WeIIs•Copy to the \!�
(i.e.auge,rotary,cable,direct push,etc.) county environmental health department of the county where installed U
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA8.
13a.Yield(gpm) 1 Method of test: Permit Program,1611 MSC,RaleigbgNC27699-1611
70%a HTH pZ DATE SITE VISITED: L�.2—r!/�-2 2s
13b.Disinfelction type: Amount:
Pri na- JJ VISITED BY: