GW1--04468_Well Construction - GW1_20230710

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-�%'WJEL L CONS TR'UJCTIION RECORD (GW-1) For Internal Use Only: o.
1.Well Contractor Information:
a•" t Aii---) 19.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
S 5 ' 11T it. Oa ti .50 GPM Our
NC Well ontractar Certification Number 15.OUTER CASING.for multi-cased-wells ORI;INER(If ap lieahle) '•i 1
YADKIN WELL COMPANY,INC. FROM I TO - 1 DIAMETER � �s MATERIAL y
ft. If ft. C in 1 -I
j Company Name 16.INNER CASING OR TUBING
2.Well Construction Permit#: be FROM zo (geothermal dosed-loop) In
�Q DIAMETER TEl MATERIAL 1 t
List all applicable well construction permits(�,U[ Count, tate,Variance,etc.) jft n � ft 4® 1 __i-rs� �, in. � �� GPI V�un��
3.Well Use(check well use): I mil...Om/ft.
in•
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A.gticultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) 042.esidential Water Supply(single) - ft, ft. in.
❑Industrial/Commercial DResidential Water Supply(shared) 18 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. 911 ft- BM ChiS la 06145
ft)
❑Monitoring ❑Recovery ft, ff.
Injection Well:
-
ft. ft .
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EmeL ACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
U Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,Lard ess,soil/rock type,grab]size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft � ft. sOiy/
4.Date Well Completed: l®-- rell 1D# AA ' J J 2,4 ft• ft.
ft. ft
5a.Well Location: Phone #-r.2, 3 785
• CAr88c BeiVey Ql f-.73 y-gyied ft. ft
Feeiility/UwnerName Facility ID#(if applicable) ft. ft
Physical Address,� City,and Zip ft ft III( 10 �U[J
A///C/ir 21.RF.MABICS
County Parcel Identification No.(PIN) 1 n:;: ,-1.!•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)ci 22.Certification:
�4ers6.37 N lei 49. -4Q59 W v 7.- 3
6.Is(are)the well(s): Itermanent or DTemporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certifio that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1 Io 1SANC4C 02C.0100 or 15A'CAC 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 1121 remarks section or on the back of this form.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i ./ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: I(q 9-- (ft.)
For multiple wells list all depths If different(example-3(0200'and 2(§100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level Is above casing,use"+" ID qInformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 60 7711 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WEI.1'S ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield Permit Jran.1611 MSC,Raleigh,NC299-1611
(Rpm) 5 Method of test: Q vto_ --a.2.„
13b.Disinfe e 70%HTH Amount- Oz DATE SITE VISITED: /.G ~` �.2`,
ction typ . u -
1-1
r
911
Fotm GW-1 , '.is Revised 6-6-2018