GW1-2023-00720_Well Construction - GW1_20230113

VaLL COIdSTRUCTI'ON RECORD (GW-1) For Internal Use Only:
1.`-Well Contractor Information:
�D wil 14.WATER ZONE,S
FROM TO FDESCRIPTION
We11 Contractor Name l j 9(/ ft. /7.J-rt.
30,16A ,�7g ft. ag-ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER Tfficra�Ess MATERIAL
ft. in.
Company Namc 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: PP w L Z o ea z 0 2ct c(a FROM To DIAMETER THICI=SS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) fit. I ft- (q tt ( cf in. n_ 1 v C
3.Well Use(check well use): ft ft. m. F Vn
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑M icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: ft. d a G rc,y t
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I MATERIAL. EnIPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. R•
❑Experimental Technology ❑Subsidence Control fr
ZX
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING WG attach additional sheets if necessa
❑Geothermal(Heating/Ccoling Return) ❑Other(explain under 021 Remarks) FROM To DESCLIYlYON color,hardness,soiltrock e, sin si:s ctc.
ft. o ft. �.9 S
la-on zz .� ,t. tt.
4.Date Well(s)Completed: WdIID# a /
Sa.Well Location: Phone # P-�R - YF- tt U'
ft ft
Facility/Owner Name Facilay1D#(if applicable) ft, ft
WLi.mbe, Lc-,g!�)p 97oZ? ft. ft
Physical Address,City,and Zip ft ft.
S Of
(lyy 21.REMARKS
County Parcel Identification No.(PIN) ;1 � r ei S f-',Le r n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 a
(ifwell field,one lat/longis sufficient) / Q . 22.Certi cation:
�+� S� gQL N Soy gco $-3 t o W
6.Is(are)the well(s): W<manent 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 Vo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under f21 remarks section or on the back of thisform.
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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 6 a- (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3(a),700'and 2®1000 l f
f I 6,its,Q 24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: T f'�-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+/"
11,Borehole diameter- fo (in,) Bit Off:.57, 9 7 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
c ,r Permit Pro 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: �' Y � fin' g 94l t t""S/2t e1►'%
70%HTH LO OZ DATE SITE VISITED_
13b.Disinfection type: Amount:
Pr i r-t--
_ .-..,., .,......,..1(1....1:,.. nLd.l.....,F V/.,,..D..,........ b...:..d A 6 9MC