GW1-2023-00693_Well Construction - GW1_20230113

j d ,CONS—IRUCION RECORD (GTV-D For Internal Use Only:
� 1_yV11 Contractor lnfornntion:
/"/'?,� �. 14.WATER ZONES
1 FROM TO DESCRIPTION
Well Contractor Name �� �
nor/
NC Well Contactor Certification Number I �: 2023 is.OITTERCASINGformulti-usedwrIls ORIINERifa' livable)
YADKIN WELL COMPANY,INC. J FROM To DTANLETER TMCtQIEss MATERIAL
ft ft in.
Company Name �j �='�,},�'"'ice 16.INNER CASING OR TUBING eothermal dosed—loop)(`
2.Well ConshuctionPermit#: ✓� v FROM To Drsnrtr u 'THICKN, ]12ATruraT.
PP P ( Slate,Parlance etc t "e �'
List all a livable well construction en its ee.In ,County, ) ft �(� t
3.Well Use(checkwell use): ft ft. in
17.SCREEN
Water Supply Well: FRoM I To DIAIrER sLOT sIZE THICttNEss MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Rysidential Water Supply(single) ft. ft, in.
❑Industrial/Commercial Xidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EM LACEMENTMETHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
I9.5ANDlGRAYEL PACK if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Sto mwater Drainage ft ft•
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILUNGLOG attach additional sheets ifnecessa ('
❑Geothermal(Heating/Cooling Retum) []Other(explain under##21 Rematics) FROM xo DEseRzpxxoN cplor,hardness,soiVro rk a .is s;u etc
4.Date Well(s)Completed: Well ID# ` ' '--t t ft' U '
Sa.WellLocation' Phone #� �`�L.�`g«3 ���� � L1 i� ft
ft ft
Faoility/OwnerName Facility ID#(if applicable) ft. ft.
ft ft.
Physical?Address,City.and Zip
/l it ft.
KL Catt 91-XG�- ��r<�' z1.REMARIGS A
/G1 .f1�1 i
County d Parcel ldenti£cationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 3 50
(ifwell fieeK one lat/longis sufficient) 27.Certification: �7
31
� $ N 9 0 rf� 1�' W
6.Is(are)the well(s): ❑Permanent or ❑Temporary afore ertified Well Contractor- Date
By signing thisfarm,I hereby certUy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IgNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repalr,fdl out known well construction information and erplain the nature of the ofthis record has been provided it;the well owner.
repair wider i21 remarks section or an the back ofthisfo m. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarl�Box).You may also attach additional pages if necessary,
drilled:, 1 24.SUBMITTAL INSTRUCTIONS
1 a'
9.Total well depth below land surface Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdierent(era ple-3(a)200'and 2@100D
74a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
ifwaier level is above casing,use"+"
11.Borehole diameter ( ) Bit Off: c zJ ?Ab.For Injection Wells: Copy to DWR,Underground Injection Control(RUC)
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 pusb,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
t Permit Program,1611 MSC,Raleigh,NC 27699-16I1
13a.Yield(gpm) Method of test: N-4 A-
13b.Disinfection type:
70%HTH OZ DATE SITE VISITED:
Amount:
d no VISITED BY: �� � �``� 1 �8'3
Pri nP
V—rw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6 2018