GW1-2023-01788_Well Construction - GW1_20230223

�ial�T�liTiZLTCTII'CDl-T RECORD ifGW-1) For Internal Use Only: —f--
1.Well Contractor Informotion:
f' "-0 LEA 14.WATER ZONES V "
11RON4 TO DESCRIPTION
Well Contractor Name //Z ft' 113 ft.
3 u A r 6 x ft. /7a ft. .s
NC Well Contractor Certification Number IS.OUTER CASING for multi- d wells OR LINER if a livable
YADKIN WELL COMPANY,INC. FROM TO DIAMIITF:R THICIQIESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR T[1B1NG(geothermal dosed-IOo )
��1 a �J FROM TO D1AN1EJJ,5 TEMG SS N2ATERrAI
2.Well Construction Permit#: Y=1/''+'L 20 e- '--U J-5 -9 —
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) .F ft D it r��, in.
ft ft. in.
3.Well Use(check well use): _
17.SCREEN
Water Supply Well: FROni TO DLkMSTER SLOT SIZE THICKNESS MA'rruteL
❑Agricultural ❑Mimicipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) T csidential Water Supply(single) ft. tt. in.
❑Industrial/Commercial []Residential Water Supply(shared) 18.GROUT _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: `/ ft. ft. 4, r 6
❑Monitoring ❑Recovery ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERW, EMPLACEMENT METHOD
❑Aquifer Test ❑StDiruwater Drainage ft'
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLTN LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO I DF.sCR]PTIOx color,harane:s,soil/m k 4 aiu size,etc
v G(ft. 7 - ft- S" *
4.Date Well(s)Completed.0q J—A�3 Well ID# ~ S-/0 -7, ft' Qf( ft- .St.JJ 4",e.
ft �GaZ ft t7�+r� Gtv/1•'��.
Sa.Well Location: Phone # 2,.r;3- 2 sk--- 5�f�fil
ft. ft
4S1rZ'liv"s S
Facrihty/Owner Name rr (� I' n ` Facili-tyy ID*(if applicable) f ft. ft.
W!`t`, 9( OCXt C { F�c[t/r11✓I� ft. ft
ft ft.
Physical Address,City,and Zip _
21.REMARKS
count) f Parcel Identification No.(PIN) v` !
&4,
R
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees. —
(ifwel)field,one latllong is sufficient) 22.Certification:
6.Is(are)the well(s): kf ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or mil. 15A NCAC 02C.0100 or 15A NCAC 01C.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 f21 remarks section or on the back of this form. 23,Site diagram or additional well details:
S.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 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if neeessary.
drilled: 1 ] 24.SUBNV=AL INSTRUCTIONS -�
9.Total well depth below land surface:
For multiple wells list all depths ifdifferent(example-3Q200'and2©100� Submit this GW-1 within 30 days of well completion per the following:
742. For All Wells: Original form to Division of Water Resources (DWR),
10,Static water level below top of casing: (ft.) Formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaier level is above casing,use"+"
Bit Off: Ll 24b.For Injection Wells: Copy to DWR,Underground Injection Control (TUC)
1L Borehole diameter: (in) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY 4
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 depwtnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producicg over 100,000 GPD: Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Ralt:igh,NC 27699-1611 �' ✓.
13a.Yield(gpm) Method of test: !`4
1 $
op DATE SITE VISITED:� `
13b.Disinfection type: 70/ HTH Amount: OZ
x, -vlt 4VISITED BY: I).l�� - -