_Well Construction - GW1_20230315 (63)

For Internal Use Only:
1.Well Contractor Information:
�-'e.v v''o°'C i 14.WATER ZONES
Well Contr FROM TO DPSCRIPTION
ctorName
F ft. ft, q
NC Well Contractor Certification Number 15.OUTER CASING formultl-cased weUs) RLUMCUap linable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TBICIarEss MATERIAL
Company Name 41 Sp ft 6, in. QU- AVC
16.INNER CASING OR TUBING eothermal closed-too )
2.Well Construction Permit#: ! � FROM TO DUNMI- R TMCKNrSs 1%T&TRRLAL
List all applicable well constructlan permiis(ie.DIC,County,State,Variance,eta) ft in.
3.Well Use(checkwell use): in.
Water Supply Well: SCREEN
FROM TO DIAMETER SLOT SIZE TBICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. to.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it.
❑Industrial/Commercial ❑Residential Water Supply(shared) iB.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD BkAMOIINT
Non Water Supply Well: ft. ft. f I
PP y � �.� b/� ?1 -114 i'.v &,e
❑Monitoring ❑Recovery 3 ft ft. /k
Injection Wel1. a "'"�
ft. ft
❑Aquifer Recharge ❑GroundwatcrRemediation 19.SAND/GRAVEL PACK ifa licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EDIPLACMZLKTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft t.
❑Geothemmal(ClosedLoop) ❑Tracer 20.DR1LLING OG attach additional sheetsif necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,h.ardaas,SoWmrktypa grain sae,cm
4.Date Wells)Completed-Ak1= Well ID#/4 [ 10 ft, fL
•� ozR e;.� ( mr �
5a.Well Location: Phone #33a-'14 61-05 ft' frl>
ft' 0- ��� � •'°�
L o/iel< dh ft 1®`; i i rl l
Facility/Owner Name -�- Facility ID#(if plicable) ft. ft.
ft. ft
Physical Address,City,and ft ft. -
21.REIYTARKS U A n 1 v; -1 q
County Parcel Identification No.(PIId) r b
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwallfreld,one lat/longis sufficient) 22.Certific
f411.e�
-' �a3
6.1s(are)thewell(s): VPermanent or, ❑Temporary of CertifiedVTellContmctor FDatB
y signing thisform,I hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ;Io ISANCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction,Standards and that a copy
If this is a repair,fill out/mown well construction information and explain the nature of the of this recordhas bamprovided to the well owner.
repair tinder#21 remarks section or on the back of this form.
23.Site diagram or additionalwell 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 GWI,is needed. Indicate TOTAL NUMBER of wells (add See Oyer'in Remarks Box).You may also attach additional pages if necessary.
drilled: `(, 24.SUEMP►TAT.INSTRUCTIONS
9.Total well depth below land surface: ® yc (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3V 00'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use
f Static water level below tap of casing: (ft') Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
Bit Off: ' 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(Le.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'k
13a.Yi el d(gpm) r + Method of test: PennitProgram,1611 MSC,Raleigh,NC27699-1611 JI�'
70%HTH OZ �WISITED
T E VISITED:
13b.Disinfection type: Amount:
t
- BY:
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