GW1-2023-00724_Well Construction - GW1_20230113

.S TRUCTION RECORD(GW-1) For Internal Use Only:
; ;: ,otractor Information:
41,'3 14.WATER ZONES
el?Contactor NN TROM TO DES TION �-
aft Wt1ft. yr t2�ck
ft. ft
xc well Con etor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER d a ticahle
YADKIN WELL COMPANY,INC. FROM To DIAM>sTER TENIINEss MATERIAL
ft. I ft. I in.
Company Name 94,i6e) &, �3 2 SLJ� 16.INNER CASING OR TUBING( eotherma]closed-loop)
2.Well Construction Permit#: 31 -7�,.,J FROM TO DIABEMR THICIQVL.SS MATERIAL -
in-
List all applicable well construction permits(r e UIC,County,Sla[e,Variance,etc) ft `f ft
3.Well Use(check well use): % ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TIiICIINESS MATERIAL
OAgricultural OMunicipaltPublic ft. ft. in.
M❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. ln.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT nfETOOD&AMOUNT
Non-Water Supply Well: ft. 4�° ft P ,• #
❑Monitoring ❑Recovery 4 °ft 3'ft
Injection Well: ft. ft
OAquifer REcharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK Qf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EnrPLACEMMNT m=oD
❑Aquifer Test ❑StDrmwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. 5
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neema
❑Geothermal(Heating/Cooling Rot im) ❑Other(explain under#21 Remarks) It
iff!L
To Dastsr>PTION(color,hardness,:oivrork n:ae,ctc
4.Date WeII(s)Completed: Z'�''7" Well ID# ��2-1 y .�' �► /k
5a.Well Location: Phone #,3� 7� CoSex3s60 K G�•�P
i,eA 56� 3 ft 47
c�k Ols�.•:
FacJ7ity! er'Ne//me Facility M#Cif applicable) 3 It a,?It eypt.1
ft ft.
Physicsl Address,City.Ed Zip
Spa e 5 21.RpEA ARILS
Cp�{j /�( Parcel Identification No.(FIN) � 0 3 - e� �� I /C t '!h
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - load
(ifwell field,one lat/longis sufficient) 22.Certification: �•31l
6.1s(are)the well(s): 4ermanent or ❑Temporary li of Colified Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.1s this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided 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 wcll construction info
construction,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.
dn7led: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: jQ6 3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@2 'and 2@100�
ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5tatic water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 1
Ifwater level is above casing,use"+"
rN v
11.Borehole diameter: ta7 (in.) Bit Off: 5-.957 24b.For Infection Wells: Copy to DWR,Underground Injection Control(TUC)" c
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,C CUA
(�. Method of test: i -$'ir /01_� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ��� �,,�,1 a✓� grrti r
r
Z
c DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: OZt'"'�a
VISITED BY: L.Lta ✓�O
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