GW1-2023-01812_Well Construction - GW1_20230223

4wiLL CONS 1T1kUCTII'QN RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
c�0 CA!A Vigo 14.WATER ZONES
Well Contractor N FROM TO DESCRIPTION
c • ft. ft.
�"'.�.J7� �� a o� 'tom
--ems ft. ft
NC Well Contractor Certification Number
15.OUTERCASING formulti-cased wells OR LINER da cable)
YADK,'N WELL COMPANY,INC. FROM TO DIAMETER THICIf1VESS MATERIAL
ft. ft. in.
Company Name
� ' , 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: `� FROM TO DUML'1ER TIDCIINPSS tt TI RIAL
List all applicable well construction permits(i•e.UIC,County,State,Variance,etr-) , ftZV It
s.m. S y_1� ve-
3.Well Use(check well use): ft. ft. in. �•�►
Water Supply Well: 17.SCREEN
FROM TO DLkmrm SLOT SIZE TEICKNFSS MATERIAL
❑Agricultural ❑Municipat/Public
❑Geothermal(Heating/Cooling Supply) 0aesidential Water Supply(single) ft. it.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1B.GROUT
DInigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETIiOD&AMO
Non-Water Supply Well: ft ft. �( e�
❑Monitoring ❑Recovery ft. f ft.
Injectiou Well: O .31'a/I Ulm ems/
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rifapplicable)
❑Aquiftr Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETSOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20. LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRUMOx color,hardness,sail/rock type,Knan see,etc
L/ -O ft S.Tt
4.Date Well(s)Completed: y' 3 Well m# AA - L �T ` ft � �� j� ,,,�„
5a.Well Location: Phone # '}Q`f�/G-�`Z{ [ tt ft
ft fL
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft. it
Physical
'Alddmss,City,and Zip ft It
w-t 21.REMARKS
County - d Parcel IdeatifoatimNo.(PITY)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9
(if well field,one lat/long is sufficient) 22.Certification: yr
N �'t 34 3 t B� /f a
WQeir4Ex./ w /-jti/-3��
6.Is(are)the well(s): Xermanent or ❑Temporary Si a of CertEffed Well Contractor Date
By signing this form,I hereby cenyy that the wen1(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weil Construciian Standards and that a copy
If this is a repair,fdl out kmown well construction information and explain the nature of the of this record has beenprovided to the well owner.
repair under#21 remarks sectfan or on the back of this form. 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 TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ffneassary.
drilled: { i 24.SUBMrITAL INSTRUCTIONS
9.Total well depth below land surface: 3 ft
For multiple wells list all depths ifdifferent(example-3@200'and 2®100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.5tatic water level below top of casing: ' (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaier level Is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) Bit Off: 3� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,mtary,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 W
13a.Yield(gpm) Method of test: q<Ir' Permit Program,1611 MSC,Raleigh,NC 27699-16I 1
13b.Disinfection type: 70%HTH Amount: tS OZ DATE SITE VISITED: W
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