GW1-2023-00722_Well Construction - GW1_20230113

i� -i)I�SNC T�'®1�1 �C�b (d�VU-11 For Internal Use Only:
1.Well Contractor Information:
✓'(�( 7� �/ �/'(�I�//j 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 7 v
3u3G � 5-0 M
NC Well Contractor Certification Number I5.OUTER CASING for multi-cwtidwells OR LINER rf s Grable
YADKIN WELL COMPANY,INC. FROM T DIAMETER ss MATE
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Company Name %%to 3�6. �- 3 to
�/ 6.INNER CASING OR TUBING eothermal elosed400
2.Well Construction Permit#:_�kv�/i- Z�,z-2 GZ'5 S7z a FROM TO nRAM>crER THICKNESS MATERIAL
e.f List all applicable well construction pendis(L a Cowry,Stale,Variance,eta.) ft ` C/ ft I/ in. I Y
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKINESS MATERIAL
❑Agricu]tura] ❑MtmicipaUPubl}c
❑Geothermal(Heating/Cooling Supply) C4k"esidential W terer Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
Chrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft' S ft. ,, G rq v y
❑Monitoring ❑Recovery it. ft.
Injection Well: ft tt
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Qf a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier rROM To MATRRTIT. EAKPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRII.LING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM TO DESCIIPTION mlar,hardnm,soil/mckcin shr,etc
0 ft, /02 '0 ft Jo,
S a. K
4.Date Wells)Completed:/-2"-2 d Z Z Wen m# F" 4 D 7 1 Ao && 6 7Si So 1Ft G r n,,
5a.Well Location: Phone #Luhc 33C•'32�� s7 6xra k02 f` '714,
ft ft
�-�► e kTc�.�ry. T. y 336- %b1-2-w
Facility/Owner Name 11 Facility
l (if applicable) ft fL
Pbysical Address,City,and Zip ft. ft
21.REMARKS 1
County Parcel Identification No.(MD ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 9 -(a
r "A(if well field,one lat/loag is sufficient)
22.Certification:
3G" 32 3g$ed" N 806 F-3 ` 1.3.Ok W
6� /Z-.20-2-Z, C�
6.Is(are)the well(s): 13Permanent or ❑Temporary Sifnature of Certified Well Contractor Date y
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 IINo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction biformation and explain the nature of the of this record has beenprovided 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 GWJ is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: P, 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: r-+ c2_ (ft.)
For multiple wells list all depths lfdfferent(example-3 r©200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells- Original form to Division of Water Resources (DWR),
Ifwaterlevellsabovecasing,use
f Static water level below top of casing: (ft-) �rm�on Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
11.Borehole diameter: (in.)
Bit Off: 6,1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
n
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
o Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm} s� Method of test:_rho air (�
13b.Disinfection type: 70%HTH Amount: $ OZ DATE SITE VISITED: -I Z- 2 Z_ �t
Pri nP c
VISITED BY: n�