GW1--03421_Well Construction - GW1_20230516

CONSTRUCTION UCTI'ON CORD (GW-1) For Internal Use Only:
1.Weil Contractor Inforrantion:
14.WATER ZONES
x FROff' .
TO DPSCrCrFnON
Well Contractor Name 7U ft. area •5 GSM Cel
�-� q2. t 1�1 ft 1, &PA11 C)Cei-
C Well Contractor Certification Number 15,OUTER CASING formulti-cased wells ORLMR. if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMITER THICKNESS &IATERIAL
e ft, ft. in.
Company Name +, l 16.1NNER CASING OR TUBING( othermal closed-loo
2.Well Construction Permit#: © C7.1 7 W FROM To DIAMETER THICIINES6 ARTERIAL �T
List all applicable well construction puTnifs(i.e 1JIC,County,Sfate,Variance,eta) 16 5 it in' Y P c.
3.Well Use(Checkwell use): �ft ft. in.
V (�
Water Supply Well: 17,SCREEN _
t rROM___j TO DIAMETER SLAT SIZE THICIINESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. iu•
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Inigation ❑Wells a•10Q_ -CP13''.'; FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ~`t s"�.t: , n..-e . 1 . ft. o ft rCW5Art-)Pt A2 20g5
❑Monitoring ❑Recovery ft. ft.
Injection Well: x ft, g•
❑Aquifer-Recharge ❑GroundwaterRemed3atipn y;5-•�Ij,j,
i, r,i;r:; ^.1 19.SAND/GRAVEL PACK if a livable)
❑Aquifer Storage and Recovery ❑Salin y, ameir.y,sj0y FROM To MATERIAL EnJPLnC MENTM1'.TaOD
❑Aquifer Test ❑Stormwater Drainage ft'
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRIIS,7NGLOG attach additional sheets if necessary)
FROM To AESCRIMON color,hnrdneu,millroek a •n s'v=,etc.
❑Gecthermal(Heating/CooIing Rt turn) ❑Other(explain under#21 Remarks) FROM ft ft.
4.Date Well(s)Completed: g-1_3aa Well ID#�/qc 3 5/5' ,'� ft' 3� it-- 6)46Q� 7(G -, TT
5a.Well Location: Phone # C, ft 35 `
ft o ft SG i� r
• G��� D6er��r�
Facility/OwnerName FacilityID#(rfapplicab e) Q ft' 17S ft sRA{ w
"O d oo p er ,��� ram. n)-!5( f'' 9 s ftwhy g chi•i
Physical Address,City,and Zip d5 c,3J ft �
/r(Ji t/llc r 2z.REMARKS e
County: Parcel Identification No.(PION) ..�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification: _
3_( 3!;2 N 91 13s_1 66 G
6.Is(are)the well(s):Aermanent or ❑Temporary Signature ertifiad Well ctor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordmrce with C
7.Is this a repair to an,existing well: ❑Yes or 15A NCAC 02C.0100 or I5A NCAC 02C.0200 WL11 Construction Standards and that a copy C
If this is a repair,fill out known well construction information tdarp'lain the nature of the ofthis record has been provided to the well owner.
repair underV21 remarks section or on the back of this form. 23.Site diagram or additional well details' C
S.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 �4
construction,only 1 GW-1 is neecjpd, Indicate TOTAL NUMBER of wells (add See Over'm Remarlo;Box).You may also attach additional pages if necessary. ,(
drilled: L ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50]®+ (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdiffereni(example-3@200'and 2©100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Staticwater level below top of casing: IV (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
]fwaler level Is above casing,use"+' 9 Q
Bit Off: �o®a lY 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in') Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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) Method of test: f
13b.Disinfection type: 70%HTH Amount: 02 DATE SITE VISITED: sl -25
Pry-�� VISITED BY:� n�7lo.,.,.i..,o.,�..FZ...• ,r�.._r�. ..Cur-.a..ve Aa ad 6_6_9nik