GW1--03918_Well Construction - GW1_20230612

;,;L,y-%L L CONSTRUCTION IRECILDED, (GNV-1) For Internal Use Only:
1.Well ContractoN
nformation:
M1 PA . IV : 14.NYATER ZONES
Well Contractor Name FROM TO DESCRIPTION
SN ' _ �59 ft ( ft. Vl7
'�Fv �-•�--' d �9P G . ` ft. oC�• i0 4 /YL
a k' Rom + ot
NC Well Contractor Certification Number t n IS.OUTER CASING foraiulti-cased wells)ORLINER if a cable
YADKIN WELL COMPANY,INC. J L N a d 2023 FROM To ft ft in.DIAMETER THICKNESS MATERIAL
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Company Name , �,•-.^ry�a; ,�l;rl
t f�y�;.,..1�� � '•'�' 16.]NNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: L � �'ti'+� T FROMft. TO DIAMETER TEICIOMS MATERIAL
List all applicable well construction permits(e.UIC,County,Slate,Yariance,etc.) l � it ' s 1II' SDA
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THIL90HEss MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) pdtesidential Water Supply(single) ft. .
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® it. dE.� ft. 4 ry �1 G - p V P
❑Monitoring ❑Recovery it. ft. U
Injection Well: ft ft .�
❑Aquifer Recharge ❑Groundwater Remediation
19.SAIHDIGI2AVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM MATERIAL EWLACEi1 ENTMEMOD
❑Aquifer Test ❑Stormwater Drainage ft, ft.
[]Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Traeer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetlnn) ❑Other(explain tinder#21 Remarks) FROM TO DUCR2TION(color,hardn�,,ovroetc in sQa etr-
tit %1 / ft 3a R Sod ,�4�1�1J rG'ry
4.Date Well Completed: -a. WellID# � °'b a it S ft.
5a.Well)Location: PhOn � ft ft
�P `�25f� �'��- 3 3c�1 c c
Facility/Owner Name ll Facility/'ID#(if9yapppIicable) 43 ft 1IP7 ft.
7 ��-7 S®�[rJ b� �"nta4" I&01 l�� If� �� ft J�� V t
ft
Physical'Addiess,City,and zip ft. -710 ft. °1 rol
t k 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one let/longis sufficient) 22.Certification:
6.Is(are)the well(s): Mo(manent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby cert)�that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes- or &-40 ISANCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a copy
If this is.a repair,fill out known 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 thisfarm.
23.Site diagram or additional well details:
B.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 GW I is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ` 24.SUBN=AL INSTRUCTIONS
9.Total well depth below land surface: ��d' (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths 1f different(example-3@200'and 2©100)
Mol 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaler level is above casing,use"+" y
11.Borehole diameter: (in.) Bit Off: 6f�.�� 74b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) \�
Program,1636 MSC,Raleigh,NC 27699-1636 t
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,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: � r
13b.Disinfection type: 70%HTH Amount: 10 D OZ DATE SITE VISITED: Z1/0—2-'�, Lam„i° to
PricP-
VISITED BY: �, 0 9
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Form GW-1 losoental Quality-Division of Water Resources Revised 6-6 2018