GW1-2023-00764_Well Construction - GW1_20230112

F d�1Y�T 1i7�1L1I�II RECORD(GVV-1) For Internal Use Only:
1.Well Contractor Information:
L 14.WATER ZONES
:�+�• FRO1M TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number IS.OUTER CASING foraiulfi-cased wells ORLINER if a livable
YADKIN WELL COMPANY,INC. 1�9�o FROM To IIIAMEIT R T$It3atE55 MATERIAL,
ft ft. in.
Company Name 16.INNER CASING OR TUBllVG eothernW closed-loo C� -
2.Well Construction Permit#: ''((,, zQ FROM TO I Tmciairss MATrur�7•
List all applicable well construclon permits(i.e.UIC,Coungtate,Variance,etc) ft S ft in'
3.Well Use(checkwell use): ft ft, in. 9
Water Supply Well: 17.SCREEN
FRODf TO DIAMETER SLAT SIZE THICIQYESS MATERIAL
XAgricultural ❑Municipal/Public ft• ft. in. 3 i
❑Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft ft. in.
OIndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We1L- 0 ft' ft- t,a e� �1+ JA
❑Monitoring ❑Recovery ft ft. e
bjection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.5AND/GRAVEL PACK Cif applicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTR=, OD
' ❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Bxperimental Technology []Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 29.DRMIZNGLOG attach additional sheetsifnecusa
FROM TO DESCRIPTION color,hardness,saWmck a grain size,crr
❑Geothermal(Heating/CoolingRetrnn) ❑Other(explain under#n21-R/t:maris)
4.Date Well(s)Completed' U-� _We111D# 7 ('' ft ( ft' t•b ®,W LU 'XI ®*cpv
5a.WellLocation: Phone # 54- Z�_f7-3q°l2 o.t $ g rah' t4ldgt com i+.-- sr'+
Face'ty/O Name Facility ID#(if applicable) SO ft ft i �_ c Y
7 ! a 6r CAi 0j. `/t v "t. it _
Physical Address,City,and ,�q ft ft ,.
r.
G e V c t a'e 21.REMARKS
County Parcel Identification No.(PIN) JAI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' -
(ifwellfield,one lat/longis sufficient)
�• y /�y 22.Certification:
alp '6 1�, l N C� Z 3l �3. 7 G W �- F r
(( P
6.Is(are)the well(s): Permanent or ❑Temporary Signatnre of Certified Well Contractor Date
By signing thisfarm,I hereby cert ihal the well(sJ was(were)constructed in accordance with
7.Is this a repair to an existing well• OYes or 4&0 15ANC4C 02C.0100 or 15ANCAC 02C.0200 WEll Construction Standards and that a copy
Ifthis is a repair,fill aut known well construction information and erplain the nature of the ofthis record has been provided to the well owner.
repair under*21 remarks section or on the back ofthisform. 23.Site diagram or additional well details'
S.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 GW-1 is needed. Indicate TOTALNUMBER of wells (add See Over'in Remarlrs Box).You may also attach additional pages if necessary.
drilled:• ! gg 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: N l % (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifelifferent(example-3 00'and2Q1001
242. For All Wells: Original folio to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+"
�• Bit Off: 24b.For Injection Wells: Copy to DWR Underground Injection Control(IUC)
11.Borehole diameter: G (in.) 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
I3a.Yield(gpm)_ 1 c I!�s Method of test: a/�
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: 8^ C --2-�2- 0
Pr'i r-P- _ _
VISITED BY:
Fnsm rW-1 CarolinaDenactrnent 6fEnvimnmEntal Oualitv-Division of Water Resources Revised 6-6-201s