GW1-2023-01810_Well Construction - GW1_20230223

.,---WELL CO NS T;C UC T iI'ON RE COS dGNT-1 p For Internal Use Only:
1.Well CCo�r:tractor lnformntion:
'�"Z7/4/✓ /0 Lv/1 14.WATER ZONES
Well Contractor Name rROM TO DESCRIPT1014
3 o 3 4 A -270 ft, 7 fr.
fr. J-t� ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-rased syeils OR LINER tf a linable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICFIIQHSs MATERIAL —�-'
Company Namc ft. \r'
CASING TUBING eothc anal closed-loo
2.Well Construction Permit#: FROM To DIANIL7EFl TffiCIMESS H2ATERTAL
Lisf all applicable well construction permits(i.e.LIIC,County,State,Variance,eta.) fr. 1057
ft t^S/F. qt, D� yfr
t2 �S a
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
rROM TO DIADIEIER SLOT SIZE THICKNESS MATERIAL
. ft.
❑Agricultural OMunicipal/PubIic ft in
❑Geothermal(Heating/Cooling Supply) )(Residential Water Supply(single) ft. ft,
❑Industrial/Conarnercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM zo MATERIAL- EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply Well: ft' g.
❑Monitoring ❑Recovery ft. ft
Injection Well: _
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery Barrier Salinity Baer I i SAND/GRAVEL PACK(ifa Grabte)
011f TO MATERIAL. E11IPI,ACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
El Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DI+SCRiPT72Tt(color,hardness,soil/mck tvpe �nia svt ett)
ft. to o ft. 01 L
4.Date Well(s)Completed: « 7 Wellm# — , !oo ft, v43 ft. GCu�►��{
5a.Well Location: Phone # 66- ?V ft ft
0!q aft, S ft. ft
Fadlity/O Name Facility ID#(if applicable) fr• ft
3fi/ Ii•'cli �6�,.��� ft. fL
Physical Address,City,and Zip ft ft.
�a,C 21.REnzARxs _
County 6 Parcel Identification No.(PIN) Al 71!�'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ram/ °y 'e
(ifwell field,one lat/longis sufficient) 22.Certification:
31� O*g4,9Yr N W
--� t
6.Is(are)the well(s): Xermanent or ❑Temporary Signature of Certified Well Contractor Dat
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 00 15ANCAC 02C.0100 or 15ANC4C 02C.6200 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 di-tails:
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 I f rW-1 is needed. 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: T 4 3 ft. W
For multiple wells list all depths IJdierent(example-3Q200'and 2Q7001 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.5taticwater level below top of casing: �0 (ft.) 24a' For All Wells: Original form ':o Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit 1617 MSC,:Raleigh,NC 27699-16I7 1!"
Bit Off: 6113 2 24b.For Injection Wells: Co to DIV Underground Injection Control )
11,Borehole diameter: (in.) PY t, gi' j (lUC
Program,1636 MSC,Raleigh,NC 2765,9-1636
12.Well construction method: AIR ROTARY
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-LouipGeothermal Return Wells:Copy to the
county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over IDD,000 GPD: Copy to DWI?,CCPCUA
13a.Yield(gpm) =� Method of test: (�`/1�► Permit Program 161I MSC,Raleigh,NC 27699 1611
13b.Disinfection type: 70%HTH Amount: 3 G OZ DATE S TE VISITED:
Pri eP- _ , ' VISITED BY: