GW1--03427_Well Construction - GW1_20230516

o-_gpr TM �L O NS TiTi'�fJC 1�I'C�I�RECORD (Cad 1-1 D For Internal Use Only:
1•WeP Contractor Inforrnntion:
&I A�—s 14.WATER ZONE,S
FROM TO DESCRIPTION
Well Contractor Name 679 AL 69/ft �r j e J -C,
015 :nA ft ft
NC Well Contractor Certification Number 15.OUTER CASING for niu16-cased wells OR LINER if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in,
Company Name 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: lD 3 L �' FROM TO I DwVMrrFR I =r7r(VEss I MATERIAI
List all applicable well construction permits(i,e.UIC,County,Slate,Marlance,etc) ft 7 ft
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROA1 TO DIAME= SLOT SIZE Tmownss MATERIAL \
❑Agricultural ❑Municipa]/Public fr.
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) it. ft. in. l
❑Industrial/Comriiero'iai ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 31 ft.
❑Monitoring ❑Recovery
Injection Well:
DAquiferRecharge ❑GroundwaterRemediation ft ft
FROM TO M
❑Aquifer Storage and Recovery ❑Sali�y BarrierSANn/GRAVEL PACK livable)
RATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stoirnwater Drainage ft• ft•
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20. GLOG atlach additional sheets ifnecessa
❑Geothermal(Heating/CooIing Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrockr,gnqu sirs,etc
a.Date Well(s)Completed: o-9 3 Well ID# f4 57,ft oo ft. Ph,& i•P �•e.
5a.Well Location- Ph011E# / �3 / f" t �B•�fr P� �' �
/� _1L 9
_LLS�a•Gl�� � """ tr ft. ft i �—,,w.y ti s' }T..
Facility/OwnerName Facility IDii(if applicable) ft. ft
6r'!/t��Gl-"�aS.Gtl��h ��YI•�� ��' ft. ft .. .,
Physical Address,City,did Zp �?�"' ft n:i
''/ 21.REA ARKS -`
County `:� : '; Parcel Identification No.(PIN) n e s A I—F w4 C elm
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaUloagis sufficient) 22.Certification:
3 5- q 4ee�9' N 17fie1 �W
6.Is(are)the well(s): ermanent or ❑Temporary Sign "e of C ed Well Conhactor Date
By signing thisform,I hereby cert#y that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 'Wo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fist!out)mown well construction information fed explain the nature of the of this record has been provided to the well owner.
repair underZI remarks sea4ian or on the back of this farm.
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 OW-1 is need. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessmy,
drilled:
- Z4.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: fit,
For multiple wells list all depths!f dierant(example-3 00'and 2©100D (ft-) Submit this GW-1 within 30 days of well completion per the following:10. ;
74a. For A11 Wells: Original form to Division of Water Resources
Static water level below top of casing: �� (ft•) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 � )�
ifwater level!s above casing,use"+If "
11.Borehole diameter- (in.) Bit Off: G v ® 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCT•CUA
13a.Yield(gpm) 1 Permit—Program,1611 MSC,Raleigh,NC 27699-I6I1 Method of test:
E VISITED:T
70%HTH Oz DATE SIT
_13b.Disinfection type: Amount: �,� /,
VISITED BY: (/
L=; i rhnent o�onmeo tal Quality-Division of Water Resources Revised 6-6-2018