GW1-2023-00718_Well Construction - GW1_20230113

WELL-C-d- NSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Al, J- j g h- [ ') :J L'"n 14.WATER ZONES
Well Contractor Name FROh4 TO DESCRIPTION
3G fit, j�rft.
3 03 6 ft. ft
NC Well Contractor Certification Number 15.OUTER CASUgaffor mulfi-cased wells OR LINER rf a licable
YADKIN WELL COMPANY,INC. FROM DIAME Tffir�vEsS MATERIAI.
ft. ft. in.
Company Namc f 16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#:PR(/�/L Z 02 2-OL,t 7 0 FROM To DIAMETER THICKNMS n4wTERLtL .�
Lisr all applicable well construction pennus�l.e.UIC,Count,State,Yariance,etc) / leJin.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TE[ICKNFSS MATERIAL
*gncultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft.
❑Industdal/Commeacial ❑Residential Water Supply(shared) le.GROUT
jprn on ❑Wells>100,000 GPD FROM TO MATMUAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 011. 6 ft.
A
❑Monitoring ❑Recovery ft ft.
Injection Well: ft ft /� /�
❑Aquifer Recharge ❑Groundwater Remediation t'1
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMriAcrmxNT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothcrmal(ClosedLoop) ❑Tracer 20.DRILLINGLOG attach additional sheets if necessary)
FROM TO DESCRIPTION .tor hardness,solYrack Frain Sur,c
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft Uv ft• Sos`� sy
4.Date Well Completed: - 30' 'VfrellID# - 13 0 ft- 11Z Z S' 6
5a.WellLocation: Phone #Jam-46/•Ck-3 fL
ft ft
Facility/OwnerName FamlitylD#(ifappEcable) ft. ft.
ft. fit
2� i:�►,.z�.G� k R L'r �l�
Physical Addresa,City,an ZIP ft. ft.
21.REMARItS
I u l�v v
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3C ` _36 lG N ShO` s 3. r•®A W --
6.Is(are)the well(s): [aKrmanent or ❑Temporary Signature of Certified Well Contractor Date
� � By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IDIQo 1 SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill oul known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 121 remarkr 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 U
constuction,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. a
dulled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3@200'and 2@100�
/�C� 24a. 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 (in.) Bit Off: 6 d4 t 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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 '.j
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: l 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Method of test: f\/4 GJ/ Permit Program,1611 MSC,Raleigh,NC 27699-1611 r�, t�`ty�����
13b.Disinfection type: 70%HTH Amount: 3� OZ DATE SITE VISITED: V2
Prime_ _
VISITED BY: