GW1-2023-01869_Well Construction - GW1_20230222

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y�.,,u,0, TS!L 'UC1TI-ON iR1t.tCORD(tQW-1) For Internal Use Only:
1.Weli Contractor dnformation:
1
rexs. _.e Lwyy-e r �S�• la.WATER ZOYLts I I
PROM TO D7 SCRII II ON
Well Contractor Name 1 �P�
�, ft 0 ft. 1i5 G!-) ft. ft
NC Well Contractor Certification Number
15,OUTERCASING•forIHN-casedviells ORLINER(if a licable
YADKIN WELL COMPANY,INC, aROM xo pLAMETER rffictQrEss MATERIAL
ft. ft in.
Company Name /� e�1 g,�9 �y ter, 16.INNER CASING OR TUBING( mthermal closed-loo
2.Well Construction Permit#: D.2 —aG- wlU�/n 'c��lrvb FR xo DIMI'T xHIcra4Ess T7ArLRIAL
List all applicable well construction pem lrs(l.e.UIC.County,Slate,TIbrianca,etc.) f ft L"t� ft 6, in. ` f) !
3.Well Use(checkwell use): ft• ft• in. J /�
Water Supply Well: 17.SCREEN
I7t0M TO DIAMETER SLOT SIZE I TEaL1MSS MATERIAL
❑Agricultural ❑M�unicipal/Public ff. ft. in.
❑0aothmanal(fieating/Cooling Supply) Eik sidential Water Supply(single) it. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1B. OUT
❑Irrigation ❑Wells>100,000 GPD TO MATERIAL EWLACLMENTAMTROD&AMOUNT
Pion-Water Supply Well: ft �ut/rS/µ
:Pe-51 ewe
❑MDnitoring ❑Recovery ®
Injection well: ft
❑Aquifer Recharge []Groundwater Remediation 19 SAND/GRAVEL PACK rf a lirahIe)
❑Aquifbr Storage and Recovery 05alinityBarrier FROA4 TO I MATERIAL. I: LACLMENTmrHOD
❑Aquifer Test ❑StoimwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control fL it
❑Geothmmal(Closed Loop) ❑Tracer 20.DRIIL7NGLOG fattach additional sheetsifneeessa
❑Geothermal(Heating/CoolingRetuin) ❑Other(explain under 921Remarlts) FROM To AESCRLPIION w1or,hard=,s lllraektyp4 gnuu size,cte
4.Date Well(s)Complete4 �Ly1 "� WeII lD#) 4P o'1 q 1 n 3 o S, fl' / S'
5a.Well Location: Phone # 38 ft t
g� a�
� 7 a astzl� l ft ��t7\ �
Facility/OwnerName FaeilityID#(ifapplicable) ft' 3��°�R
ti ft ft.
Physical Address,City,and Zip' ft ft t y �02
21.REIISARICS
County Parcel Identification No.(P.IId) 1'0=. �^:n•,
vli:I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaUlongis sufficient) 227Certification
yv
6.Is(are)the welI(s): IR ermanent or I ❑Temporary Si e o ertified Well Contractor Date
By signing thisform,I hereby certify thal the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I ya b ISZ NCAC 02C,0100 or 1SA NCAC 02C.0200 Well Construction Randardr and that a copy
If this is a repair,fill out kmown well construction information and explain the nature of the of this record has been pravided to the well owner.
repair under#21 remarks section or on the back ofthisform.
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,is needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages.if necessary.
drilled: I� �® 24.SUS117IT TAI,INSTRUCTIONS
9.TotaI well depth below land surface: '37 � (ft)
For multiple wells list all depths tfdi�erenf(example-3@200'and 2©I00D Submit this GW--1 within 30 days of well completion per the following:
10.Static water level below tap of casing: 24a. For All Wells: Original forin to Division of Water Resources (DWR),
(ft) 1�
Information Processing Unit; MSC,Raleigh,NC 27699-1617
Ifwafer level Is above casing,use"+" t
ic Bit Off: 4,07 24b.For Injection Wells: Copy;to DWR,Underground Injection Control(IUC) r
Il.Borehole diameter: (in.) ! ^,
Program,I636 MSC,Raleigh,NC 27699-1636 `Y
12.WeII construction method: AIR ROTARY ILA24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.,auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) 3° Method of test: /'/'o�` Permit program.1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: / OZ DATE SITE VISITED:6
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