GW1--03088_Well Construction - GW1_20230428

dP- L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information.,
fd ��,i'LP� ����✓� �14YWATE$`ZONESi:'i::�;i':.::::�: .., ...:. . . _
FROM TO DESCRIPTION
Well Contractor Name y cy
25g 7ft gi
NC Well Contractor Certification Number
15:'OVIER:CASiNG(for'm`rilti=' ed:wells'.ORIIlVFIC if a' licable;--. ::.: '
Yadkin Well Company, Inc. FROM To I DL THIcI4iEss MATERIAL
ft. ft in
Company Name �� [+^�,��
`:;15:MFIY CASING'OR.TUBING "eoffiermal"clo"sed`lo'o" '- '--• '--
2.Well Construction Permit#:�'(3� / �� FROM To DIAMETER THICS4VFSS - MATERIAL
List all applicable well constructionpermits(Le.WC,Cowdy,State,Variance,etc.) � ft. ft � �/d m � _ ��/�
3.Well Use(checkwell use): ft ft in.
Water Supply Well: - -- - ----- -
]?P y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft m
❑Geothermal(Heating/Cooling Supply) aesidential Water Supply(single) t ft in•
❑ clustrial/Commercial ❑Residential Water Supply(shared) --_- -
18 GROUT_ - �- - - - -- - -
❑Irri lion ❑Wells>100,000 GPD FROM To MATMUAL EMPLACEIYILNTMETHODBcAMOTINT
Non-Water Supply Well: ft. q ft.
❑Monitoring ❑Recovery ft r� ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
i'19:.SAND/GRAVFdsPACK:ifa liralile
❑Aquifer Storage and Recovery ❑Salinity Barrier [1;zROM TO MATERIAL EMPr.ACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft ('
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer DRILIIlVG'L"OG attne]i ndditionalsheef�ff necess __. :_ _ -___
FROM TO DESCRIPTION(color,hardness solVroek type,grain stxe,eta
❑Geothem:al(Heating/CoolingRetum) ❑Other(explain under#21Remarks) ft. �� ft �°�rt� ��
Date Well Started 3A I—a3 y
4.Date Well(s)Completed: o a1- WeIIID#, o /o � ft. V ft 6�� 44,
�'1Q� $ G�
Sa.Well Location: Phone#: ® - Z- �i kss ft. 32,?- ft iVul
Facilitylow=Name Facility M#(if app A-k-� ft ft
l�1.
ft. ft A
Physical Address,City,and Zip ft ft lfpy,-:C t ter S�7'erPr� fly
County _— Parcel Identification No.(PlN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) ® f 22.Certificatio
6.IS(are)the well(s): 9Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or dNo 15ANCAC 02C.0100 or•154 NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has beenprovided to the well owner.
repair under#21 remarks•section or on the back of this form. 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 G$J 1 is needed. Indicate TOTALNUMBER 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf different(example-3Q200'and 2@1001
1� 24a, For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: b (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water'Tevel is above casing,use"+"
) LOW s9 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
(,m
11.Borehole diameter: . Bit Off: %!1' Program,1636 MSC,Raleigh,NC 27699-1636
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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR CCPCUA
13a Yield(gpm) Method of test: Air `x
Permit Program,1611 MSC,Raleigh,NC 27699-1611
V 70/o
Date Site Visited: r
o hth oz a
Site Visited B
13b.Disinfection type: Amount: Y�
Form GW-1 - _. Noah Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018
Price: i (
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