GW1-2023-00688_Well Construction - GW1_20230113

b 1{ �IYS1iR'NC11ION RECORD fGW-1) For Internal Use Only:
] Weil 1 Contractor Information:
irou 5'e ��''� ✓mil
�, 14.WATER ZONES {�
Well Contrartoor Name
7O� TO DESCRIPTION 1
NC WeU Contractor CerUcationNumber JA lv r• n 15.OUTER CASING foraiulti-rased wells OR LINER rf a licahle
d ZL/ FROM TO DL\ME rEIL TffiCKNESS MATERIAL
YADKIN WELL COMPANY,INC.
lrr t
.,:'•.,^,,_ ft. Sq ft. 6195 in- SCR-JL! PV e-..
Company Name ^a, ,
���� � ":>'�:::,, ._"=7J'Jrf 16.INNERCASMG OIL TU13ING eothermalclosed-loo )
2.WellConstuctionPermit#: �'�� J FROM To DIAIVlrER Tfficraarss MATERIAL
List all applicable well construction pei7its(i.e.EUC,County,Slate,Variance,eta) ft ft
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THIC[aYESS MATERIAL
❑Agricultural ❑M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) Q16sidential Water Supply(single) it.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEhIENT AM,THOD&AMOUNT
Non-Water Supply Well: ® ft 91 ft. 8•'AT�a�aP'�( a 4 �✓� �� ���-�
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.5AND/GRAVEL PACK Qf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M&TERILL EMPLACrMENTMETHOD
❑Aquifer Test ❑Stine water Drainage ft, ft
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRMLINGLOG attach additional sheets ifnecessary)
❑Geothermal(Heating/CoolingRetnm) ' ❑Other(explain under#121 Remarks) FROM To DESCRIPTION rular,hardness,saivrork eta
d.DateWells)Completed: �l/ce � We11ID# "Z sc Ct, ft• i1p ft. 1, -er 24 '.-IC 4-st" l
5a.WellLocation: Phone #.33C - �Ct- 72PeZ e JL( ��as+n,t' .CSc+� --'
6�V t°> l� �,� s 3-X-We-a l�i3" l
Paclty/O Name acilify1D#(rfapplicable) �� ft- a ft' ]I 1t
32-S R,twac S�adl R-4 S'� �'�l ft. ft.
Physical A
dd
ress,City,and ' ffi ft'
21.RFNRARICS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/longis sufficient) 22.Certiff 'on:
6.Is(are)the well(s): OQPermanent or ❑Temporary rgo a of Certifed Well Contractor Date
By signing thisform,l hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing weII• ❑Yes or X1\1- 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction,Standardr and that a copy
lfthis is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarkr section or on the back of this farm.
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 hah
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlts Box).You may also attach additional pages if necessary.
drilled:, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 2-2- (N Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths/fdifferent(example-3@200'and 2©100�
SD • 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Statiew'ater level below top of casing: (ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
11.Borehole diameter (in) Bit Off: a®� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,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
13s.Xield(gpm) IL Method of test: �t s PeimitProgram,1611 MSC,Raleigh,NC 27699-I6I1
�°9•a�-b;�d(�
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: R� "�2-
- VISITED BY:-Jl p!1