GW1--03085_Well Construction - GW1_20230428

I
1dVI-L For Internal Use Only:
1.Well
�Contractor
/Iniornation:
i
'!�¢ �`l iZY.Onf ���4✓ 14.NYATER ZONES
Well Contractor Name FROM TO DESCRIPTION
U 3 6 A 3 zD ft. Z ft. i� It �Ib
NC Well Contractor Certification Numberft. �y ft S©—.7© AN
15.OUTER CASING for multi-cased wells)OR LINER if a !!cable �!
YADKIN WELL COMPANY,INC. FROM o DIAMETER THICIO . MATERLIL
Company Name ��/.(-�„ �t� _ 2 i j9-_"a 3 C.0in.
�g 16.INNER CASING OP.TUBING( eothermal dosed-loon
)
2.Well Construction Permit#: FROM TO 131,41M ER THICICIMS I MATERIAL
List all applicable well construction perm its ri.e,111C,County, ate,Parlance,etc) �-� H• G� ft. �i S,L,!n. q�-Q//
3.Well Use(check well use): ft. ft. © �� in. T'WGl(�Gn `r rl
Water Supply Well: 17.SCREEN PA
FROM I TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑AgriculturaI ❑MunicipaYPublic
❑G othermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. t. i
19�ndustrial/Commercial []Residential Water Supply(shared)
18.GROUT �!
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACLIVIENTMETHOD&AMOUNT
Non--Water Supply Well: 0 ft. �' ft. (" P �� �I
❑Monitoring ❑Recovery ft ft (� f"JS
Injection Well: 6,71 i
❑Aquifer Recharge ❑Groundwater Remediation ft. ft
❑Aquifer Storage and Recovery ❑Salinity Barrier 19•SAND/GRAVELPACK(ifa licable)
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft
❑Experimental Technology ❑Subsidence Control ft I
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG Mach additional sheets if neeessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCR ON color.hardaos.sall/rork type, in sae,cte
ft. ft
4 ate elI(s Com leted•3— (�a� a�3 Well ID# 3 ft. 6, ft• Gr� i-
Sa.Well Lo�tion: 3 F 1°d i ��
Phone # ��� -3�- Ztc2 Je ge ba.c is fa
a r !• D A! C`7 ft a ft
Facility/Owner Na
me ee FacilltyID#(if applicable) 7 ft. ft.ft. fL
ova un
Physical Address,City,and Zip LA ft APR C� 3
ti 21.REMARKS O
t..
County ParcelIdentlficationNe.(PIIQ) ��� lfl{Gi�. s.C� i�t:`:' """� Ian;
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,on^e llat/long is sufficient) p 22.Certification:
31,
6.Is(are)the well(s):Lr=�pRrinanent or Xemporary Signature of Certified Well Contractor Date
V��'' � Bysigningthisform,Ihereby cert)�that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existingM well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction SYandards and that a copy
If this it a repair,fill out!mown 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. Q
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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlo Box).You may also attach additional pages if necessary.
drilled: '70°a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ifdi�erent(example- 00'and2@110�0') —(ft) Submit this GW-1 within 30 days of well completion per the following:
r 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �J � (ft)
If water level is above casing,use"+" 1 p o Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter: �Oj t,u,l .-off 6° A O F 24b.For Injection Wells:Copy to DWR,Underground Injection Control(II1C)
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636 f
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the !
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed Copy
FOR WATER SUPPLY WELLS ONLY. 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m 100_4 Method of test: nJ�rr Permit Program,1611 MSC,Raleigh,NC 27699-1611 r
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
Pri r i-- VISITED BY: V0