GW1-2023-01811_Well Construction - GW1_20230223

W,..` 'f LL C09NS TRUC T1,0N I,,C,DED(GIV_1 o For Internal Use Onl)':
1
1,Well Contractor Informndon: `
14.WATER ZONES
s i�i V i FROM TO DESCRIPT��I++O��N
Well Contractor Nam ry
�7 •7 I�'1T ft. it.
cable
NC Well Contractor Certification Number Is.OUTER CASING for multi-cased wills)OR LINER THICIINESS AT a li M MATERIAL
FROM TO DIAMETER
YADKIN WELL COMPANY,INC. ft ft• in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
— FROM TO DL�ME7TR THICIINE55 T'[ATERIAL
2.Well Construction Permit#: 1 '1 [" ft. y g tt• �� j" $� s11 Put-
List all applicable well construction permits r.e.UIC,County,State,variance,etc) —
ft. ft. 1II•
3.Well Use(check well use): 17,SCREEN —
FoAgricultural
upply Well: mom TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft, ft. in
ermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERAL EMPLACLMENT 11SETHOD&AMOUNT �,•
❑Irrigation ❑Wells>100,000 GPD ft , fr.
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ��. ft. (3s., .51JN too,
Injection Well: ft• ft'
G
❑Aquifer Recharge ❑ roundwater Remediation 19.SANDIGRAVEL PACK(if a '.iaible)
❑Sfllnllty BalrleI FROM TO MATERLIL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ft, ft.
❑Aquifer Test ❑Stormwater Drainage —
Control
❑Experimental Technology ❑Subsidence —
[]Geothermal(Closed Loop) ❑Tracer FROM
RIP
DRILLING LOG attach additional sheen if necessa M.in sae,etc
FROM TO DESCTION(color,hardness,saiUrock q
❑Geothermal(Heating/Cooling Return) ❑Other(explain andder#21 R�eemarks) '/n ft. q'd It,
4.Date Well(s)Completed:
Well ID# AP_ z3 7C� ?93"ft' �/J�. ./{ mare• e
ft. ft-
5a.Well Location: Phone # a —
Q / �j ft. ft
/tL/ /;)f P �to )t_ ft. ft
Facility/Owner Name Facility ID#(if applicable) —
/6i2
Physical Address,City,and Zip Lev IS —
21.REMARKS
o+ es
CountyIV Parcel Identification No.(PN
� a�
trot
—
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(ifwell field,one latilong is sufficient)
Date
Si re of Ce d Well Contractor
6.Is(are)the well(s): yermanent or ❑Temporary
By signing thisform,I hereby certil5 that the wells)was(Here)constructed in accordance with
7.Is this a repair to an existing well: ❑Xes orI0 15A NCAC 02C.0100 or 15A NCAC G2C.0200 Well Construction Standards and that a copy
ofihis record has been provided to;'he well owner.
this is a repair,fill out known well construction information and explain the nature of the
If
repair under#21 rcmarks section or on the backofihisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells
drilled: 4ry 24.SUBMITTAL INSTRUCTIONS9.Total well depth below land surface:_ 3 O� t (ft') Submit this GW-I within 30 9ays of well completiou per the following:
For multiple wells fist all depths if dierent(example-3 r@200'and 2©]00�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S�• (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699 1617
If water level is above casing,use"+"
Bit Off: S�q� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC
11.Borehole diameter: (In.) Program,1636 MSC,Raleigb,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 pusb,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prod icing over 100,000 GPD: Copy to DWR,CCPCCUA
PetTrtit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �S Method of test: •ft. Y' *�
70%HTH OZ DATE SITE VISITED:— ��' 'i v 1
13b.Disinfection type: Amount: a•5� S F p 3 3!JZ
y ITED B Y-2
Pr i [__P --- nlal Quality-Division of Water Resou:ces Revised 6-6-2018
t:,,.r r,W-1