GW1--04012_Well Construction - GW1_20230612

T AL CONSTRUCTION li: (CllOR '1 QW-1) For Internal Use Only:
1.Well Contractor Informntion:
��� 3. ►�5 14.NYATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. C,)® ft. i Pin
Lt Sa A ft. ft.
NC Well Contractor Certification Numbs 15.OUTER CASING for multi-cased wells ORLINER if a liable
YADKIN WELL COMPANY,INC. FROM To DIAMETER' THICIME55 MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING( othermal closed-too
2.Well Construction Permit#: ��l'�C .1 1 FROM To DIAMEf'R Tmclaims MATERIALList all applicable well construction per7nils(i.e. C, ty,51a rr te,Maanm elr-) ft f G j ft 1� in. ` P J� ,
3.Well Use(check well use): ft ft. in.
Witter17.SCREEN Supply Well: rROlrr TO DIAMETER SLOT SIZE THICIfNEss MATERIAL
❑Agricultural ❑Municipal/PubIic ft. ft.
❑Geothermal(Heating/Cooling Supply) ffiesidential Water Supply(single) ft. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Wafer Supply Well: it' ft' uOIP rIV POUT4 2 ha
❑Monitoring ❑Recovery 3 it. 9 ft a� Grp P J 4112 6Ts
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(iia liable)
❑Aquifer Storage and Recovery ❑salinity Barrier FROM To MATERIAL EMPLACEMENTMEfHOD
❑Aquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft ft
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,soIL/mcktype,grain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Refmarks) ft &® ft +
4.Date Well(s)Completed: Well , dC� G d ft 102 ft' SO` .4j1'a nt�t
Sa.Well Location: ��ff P}1011B # � 101 ft B003ft 6P(ah�%p
ft.
Facility/Owner Name Facility ID*(if licab ) ft' it _ 1 •n
K"'
(5 iVeV%A env n
Physical Address,City,and Zip r ft.
{� / 7.1.REMARKS
/, -s Ci
County I //�, Parcel Identification No.(MD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3.G N :aI W 103
6.Is(are)the well(s):)1Permanent or ❑Temporary Sigalatare cW Certified Well Contactor Date
By signingthisform,I hereby cert)�that the we//(s)was(were)constructed in accordance with
7.Is this a repair-to an e.:dsting well: ❑Yes or /4NO 15A NCAC 02C.0100 or l5A 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofihisform. 23.Site diagram or additional well details: J
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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlo Box).You may also attach additional pages if necessary.
drilled: 1 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 dierent(example-3(a3200'and 2©100D
oo (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR);
10.Static water level below top of casing: S
Information Processing Unit MSC,Raleigh,NC 27699-1617 C
/fwater level is above casing,use"+",//JJ (in.) ,
f Bit Off' & 2 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Borehole diameter: (o
Program,1636MSC,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,CCPCUA C
� Permit Program,1611 MSC,Raleigh,INC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: 70%HTH Amount: 32 OZ DATE SITE VISITED: �. '�l�� •�
- ---- ----------- -----i VISITED BY: OA
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c......Mly 1 i n-,+--t 4v-irnnm-w n-iity 12-nnrree Revised 6-6-2018