GW1--03065_Well Construction - GW1_20230428

LL+CONST '1(JCTWWN 1]1ECCO]i D(GPI-1) For Internal Use Only:
.1.Well Contractor Information:__
1 L-
(,Dc\y �V .5 14.WATER ZONES -
1+ROM TO DESCRIPTION
Well Contractor Name j
55 ��vvjj ��,� ft. " ft. S �t (n ,
TIC Contractor CettificatitmNnmbcr 3cAG ft, ft 20 ! iA. a t 1' -
15.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft in.
Company Name m t
3 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TEICLCNESS MATERIAL.
List all applicable well construction permits 6,.. C,County,Slate,Variance,etc) // ft y Q ft to in. (Yyd 5 1 -a 1
3.Well Use(check well use): d ft. ft. in.
►`� S"t
Water Supply Well: - 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ® residential Water Supply(single) ft, ft, in.
❑Industrial/Commercial . DResidential Water Supply(shared) 18.GROUT
va
❑ rigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t°' ft ft. ,,� (hA Ps_ 5 kV i' 7
❑Monitoring ❑Recovery ft. ft. '
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation '
19.RAND/GRAVEL PACK(dapplic-0)1e)
❑(aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormvvater Drainage _ ft ft. ..
❑Experimental Technology ❑Subsidence Control ft. it.
0 Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG(attach additional aheeta ifnecessaay)
❑Geothermal(Heating/Cool'mgRetum) ❑Other(explain under421 ,s.) FROM TO DESCRIPTION(color,hardness,soiVrocktypr,grain sac etc.)
,. . ft. 7� ft. if 05c. 6
i
22
4.Date Well(s)Completed: J`. . Well ID#/9�/° ..
.r•j 7 i ft /40 ft a j r ipl 4
r
il
Sa.Well Location: c 3 ,r ,
Phone # �3�-���'-�',9�� -�`� ft. �' � �ca°��. �. ,
• j,9„ a / '�
"-fire- Facility t -4,: ~." p- I..- --T-•
FarJ7ity/OwnerNeme +_t.. •F.i ill--: T
ft. ft
e4�e�� Z�e- A it ft APR bZ023
PhysicafAddress,City,and Zip .
j� / 21.REMARKR !!1$7i7 :;;C i eel:';-v„drfn Uiri
County Parcel Identification No.(PIN) CV:(.V u OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fad,me 1st/long is sufficient) 22.Certification:
1p 3 ) �s<Y N g/ Q ® 30L4Y w 3 <': 3.
6.Is(are)the well(s): Mermanent or ❑Temporary Sr afore edified I Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.7s this a repair to an existing well: ❑Yes or ligo I5ANCAC 02C.0100 or'ISANCACO2C.0200 Well Construction Standards and that a copy
If this(I C repar,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair render#2I remarks section or on the back of this form. 23.Site diagram or additionalwell 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 ..
(add'See Over'in Remarla Box).You may also attach additional pages if necessary:`
construction,only/GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4)200'and 2(§100')
24a. For All Wells: Original form to Division of Water Resources (DWR);
10.Static l is above
level below top of casing: ��� (fit) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter r, (in) Bit Off' S e VI T 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(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 Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2.8 Method of test: ,e't e'' SN > 8�
75.2�.0 •
13b.Disinfection type: 70/o HTH Amount: il, OZ DATE
A 7ED B.VISITED:
.4i
' r,7 r P' rnta1 Quality-Division of WaterResources Revised 6-6-2018
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