GW1--03425_Well Construction - GW1_20230516

RECORD ('GW-1➢ For Internal Use Only:
1.Well Contractor-Inforrawdon'
��• 14.WATER ZONES
FROM TO DESCRIPTION
Well Contracto
r
Name No ft. It. / 7�
ft l�
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased vve]]s ORLINFR rf a livable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER MUCICNESS MATERIAL
ft. & in.Comp
anyName r26.INNER CASING OR TUBING( eethermal closed-loo 2.Well ConstructionPermito. 3 I G 7G FROM To DIAteI r= TmciagLss MATEREt
List all applicable well construction permits(xe.U1C,County,State,Variance,eta) ft iu' l01
3.Well Use(checkwell use):
Water Supply Well: 17.SCREEN
IIiODi TO DIAMETER SLOT SIZE' TSICfaVE55 MATERIAL
oAgdcultural ElMunicipaI/Public ft. ft. in.
❑Geothermal(Heatingicooling Supply) residential Water Supply(single) ft. ft.
❑Industrial/Coininercial ❑Residential Water Supply(shared) 16.GROUT
DIrrigation ❑Wells>100,000 GPD FROM TO MATT,RIAL EMPLACEMENTMETSOD&AMOUNT
Non-Water Supply Well- b ft, a ft. Chi 31-6-W 1
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK ifa livable f
❑Aquifer Storage and Recovery ❑Salinity Barrier mom TO 1%L1TEliTAT' En7PLACEs 16NTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft it.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLTNGLOG attach additional sheets ifnecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mcktypr,grain si+L,cte
ft. ft.
4.Date Well(s)Completed:i Well ID# P* 3 fa ft, a ft. Wvl� if�
5a.Well Location: Phone # �.28^`��V 434
�� '^
A H c-a/ /JJ/"i ft. ft
F ty/Owner Name Facility ID#(if applicable)
( / ® ft. ft. MAY
3 ' Ly 7 ft L
Physical kdr.A.City,and Zip
21.REMARKS �Li rs;;3s'.^.l r� -•:.
�llt' ! Vij•� �'- • n
County Parcel Identification No.(PIN) u t�
5b.Latitude and longitude in degrem/minntes/seconds or decimal degrees:
(ifwell Belli,one latdongis sufficient) 22.Certification:
6.Is(are)thewell(s): permanent or ❑Temporary SignatorCrif Ce_rtffieAirefltontrartor hate
By signing thisform,]hereby certi)�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I0 15ANCAC 02C.0100 or 15ANCAC 02C.0200 37ell Construction Randards and that a copy
11
Ifthis is a repair,fill out known well construction information and erplain the nature of the of this record has been provided to the well owner.
repairunder*21 remarkssectionoron the backofthisform. 23.Site diagram or additional well details:
8.For Geo robe/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 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages Hnecessary.
drilled: yy 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 li' (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3 t©200'and 2©100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ® (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
Bit Off: ��� 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUQ
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
(i.e,auger,rotary,cable,direct push,etc) county environmental health department of the county where installed .4
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) 5o Method of test: �I� �
70%HTH OZ DATE SITE VISITED: �'� _ iL
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I3b.Disinfection type: mount:
Revised 6-6-2ols
;_Form GW-1.-J �___. .