GW1--04020_Well Construction - GW1_20230612

"W,,12 CONS RIUC IONS I +CORD (GW-1) For Internal Use Only:
1.Well Contractor Inforsrition:
&1 . 14.WATER ZONES
VRO1M TO I DESCRIPTION
Well Contactor Ale
ft it
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLD if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TI�ccLafEss MATERIAL
ft, ft in.
Company Name
16.IlVNER CASING OR TUBING eothermnl closed-loop)
2.Well Construction Permit& i �(/ FROM TO DIAMETFR I TSICIa4Ess 1%TATmaAL
List all applicable well construction permits(he.UIC,County,State,Variance,etc) ft /23 It !VC,
3.Well Use(checkwell use): ft. ft in.
Water Supply Well: 17.SCREEN
I7L011S TO DIAMETER SI.oTSIZE TffiC1(IKE55 pfp7TureT.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Indushrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENTIIMTSOD&AMOUNT
Non-Water Supply Well: ft. 3 ° ft. eA "sue
❑Monitoring ❑Recovery ft " °ft.
Injection Well: ft %
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDlGRAYEL PACK if applicable)
❑AquifEr Storage and Recovery ❑SalinityBaII]er mold TO MATERIAL EMPLACEMENTMETSOD
❑A.quifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLTIQGLOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM xo DESCRIPTION colon hardness,solltrork a la sae,cte.
4.Date Well(s)Completed: o-�' &>e'L ega44
ft. ft
5a.Well Location: Phone # p��v�d'��@dt_
1 ft ft
'S F��hhh�
F /OwnerName ft ft
Facilitymm(if applicable) �,i 'G
ft. ft
GV l J 4JT�►fLt7� • `0 W. ft ft IV 1
Physical Address,City,and Zip
/( 21.REMARKS
urm
County Parcel IdenlifcationNo.CMI)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s):Wermanent or ❑Temporary §OMure of C6&ea Well Contractor Date
By signing thisfonn,I hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well' ❑Yes or (0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a co
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If ihis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well awner.
repair under f21 remarks section or on the back of this form.
23.5ite 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*ell construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:, 1 24.SUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
Fos multiple wells list all depths 1fdifferent(exomple-3(a)200'and 2©100�
1�e ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use"+" I
f Borehole diameter in. Bit Off' D 24b.For Injection Wells: Copy to DWR,Underground Injection Control (rUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construetion method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ix.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR NVATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Xield(gpm)
® Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-I611
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13b.Disinfection type: 70%HTH Amount: oZ DATEpp��S��ITE VISITED: /0
Pri nP- �. -- 6MAITED BY:- `V�f
Form GW-1 �ntal Quality-Division of Water Resources Revised 6-6-2018