GW1--06229_Well Construction - GW1_20230925

•_�LI L CONSTRUCTION)i iCO (GW-1) For Internal Use Only:
I.Well Contractor Infornintion:
3C r C 1 (tea T16 t pi S 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
. ..)y s'D aq mg ft. A i0 ft. is P
NC Well Contractor Certification Number Is.OUTER CASING(for Multi-cased*ells GRUNER(if a ilcable)
YADKIN WELL COMPANY.INC. FROM TO DIAMETER , THICKNESS MATERIAL
ft ft. in.
Company Name 16.IPNER CASING OR TUBING(geothermal closed-loop) r
2.Well Construction Permit#: QQ FROM TO DIAMETER THICICNESs _ MATERIAL .$
rXc,Co g d - i n Loa ft. G IY in. 5!�R v C.
List all applicable well construction permits i.e. County,Slate,Variance,etc.) � 1,,..
ft. ft. in. I/
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) ,esidential Water Supply(single) f ft. in. 71
❑Indusbial/Cornmercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ;a ft. 3a,t®aal. e0' Grawi47 i l
[Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTME7EOD.--
❑Aquifer Test ' ❑Stormwater Drainage
ft. ft. ,�-
[Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrocktype,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
p T 0 ft- S' ft- s-0ill
4.Date Well(s)Completed: g 19 lZ 3 Well ID# /-5J30 sa ft' 2&2 ft- G('a 0.eki. -
sa.WellLocation: / afAe Phone # 704-POJ-IVV ft. ft 1i -'�l. _ i q 1:•-- '�
Facility/Owner Name A)d vy ,ke,ry,C.t8 cility ID#(if applicable) ft. ft Er w ` ?023 }t
011.dit 5.ki-4,et /-4r,ft. a 00".4_, ft , ft. inits.rAwra ,-,,„.. -4
Physical
Address,City,and Zip ft. ft. `
i.`t% k 1 21.REMARKS
Countyf�/ �/ Parcel Identification No.(PIN) Z it.T 6 51 44 74,i42 ---,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6 /Cilg e? N gl 41‘, b? 3_/_. W ell() *19 ,P3 c4
6.Is(are) we
ll(s):s: ern Signaturk C ed Well Contactor Date
permanent or OTemporary ry
of
By signing this fonn,I hereby cert fy that the well(s)was(were)constructed in accordance with-
7.Is this a repair to an existing well: ❑Yes or o 15ANCAC 02C.0100 or 154NC4C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information andexplain the nature of the of this record has been provided to the well owner.
repair under#21 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 Sere Over'in Remarks Box).You may also attach additional pages if necessary.,,
drilled: d 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .28a (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2 r@100D
10.Static water Ievel below top of casing: /0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Bit Off: S.9 9b 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: 4 (in) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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) P® Method of test: cr je
13b.Disinfection type: 7D%HTH Amount: I f OZ DATE SITE VISITED: 3-.3...?
•
VISITED BY:' 11 13
Pri rP z
Form GW-11 inmental Quality-Division of Water Resources - - Revised 6-6-2018 `v