GW1-2023-01789_Well Construction - GW1_20230223

For Internal Use Only:
1.Well Contractor Informntion:
�� "WATERZONELL . L "� Y `'� " DESCRIPTION
Well Contractor Name G)0i 'NC Well Contractor Cart fication Number r multie11s ORLINER rf a licahleDIAMETER TffiCKNESS MATERIAL
YADKIN WELL COMPANY,INC. 4-1 ft. /y q ft-TUB14,19
/I•9_S
Company Name SSL . 16.INNER CASING OR ING/(meothermil closed-loo
FROM TO DIAMETER THICKNESS MATLRIAL
2.Well Construction Permit#: iAQ 1!V j ZO Z Z ri r— ft. ft in.
List all applicable well construction petmitr(Le T7IC,County,State.Variance,etc)
� ft, in.
3,Well Use(check well use):
17.SCREEN
Water Supply Well: FROM I To DIAMETER SLOT SIZE TMCIINESS MATERIAL,
❑Agricultural ❑M�lmicipaLTublic ft. I in.
❑Geothermal(HeatinglCooling Supply) (3itasidential Water Supply(single) ft I ft,
❑Industrial/Commescial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERUL EMY1 ACEMENT METHOD&AMO
❑Irrigation ❑Welts>100,000 GPD
Non-Water Supply Well: & ft. ft. [siryNri C 1tr ka 1>n le.0
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge []Groundwater Remediation "DRRIING
rf a liable
❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL EMPI-ACEMLtNT METHOD
❑Aquifer Test ❑StDrmwater Drainage❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer h additional sheets if necessary)
FROM TO DESCRD:lYON color,hardaus,soiVrork e, in Sias,etc
❑Geothermal(Heating/Coolmg Rettun) ❑Other(explain under#21 Remarks) O ft D fL .s e( ( ,� S-
4.Date Well(s)Completed:b 1 I fJ JP 23 Well1D# ````',^� 75 M
5a.Well Location-. ,( Phone #:I , '3:� �
� t t
- v
l: � �b ff. (t ( it
Fac17ity/Own Name
Facility M#(if applicable) ft' y ft I I 1
ft. ft
VI7 I (-41 �N ys' .� Tl�vrn � N
2 2� VkO� ft. ft.
Physical Address,City,and Zip A%U
21.
S REMARKS � 1
u��
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) erti ca n:
Si Certified Well Contractor Date
6.Is(are)the well(s): N4 rmaneut or ❑Temporary
!& signing thisform,]hereby certify that the well(T)was(were)constructed in accordance with
7.Is this a repair to an Busting well: ❑Yes or me/11 15ANC4C 02C.0100 or 15ANCAC 02C.0200 Well Construction Randardr and that a copy
Jffhls is a repair,fill out known well construction information and explain the nature afthe ofthis 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 well construction info
construction,only 1 GW- Is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: T (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2©1001
/f% 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (OL-(ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Jfwaier level Is above casing,use"+"
Bit Off: v(Q 7�► 24b.For Injection Wells: Copy to DWR,Underground Injection Control (TUC)
11.Borehole diameter: (in-) Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: AIR ROTARY 24c.For Water 5upp1V and Open-Loop Geothermal Return Wells:Copy to the
(ix.auger,rotary,cable,direct push,etc.) county environmental health deparonent of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
y 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
Ar
13a.Yield(gpm) L�(% Method of test: � ` /� �V
13b.Disinfection type: PM
HTH Amount: 9 OZ DATE SITE VISITED: l0 2�-2-Z 3q ,41Ji
VISITED BY: -
P r i r`A Revised 6-6-2018
—^,,, r'irorinlental Quality-Division of Water Resources