GW1-2023-01813_Well Construction - GW1_20230223

CONSTRUCTION RECORD ('GW-1) For Internal Use Only:
1.Well Contractor Information: JLl
14.WATER ZONES
FROM To DESCRIPTION
Well Contractor Name 1 ft. 36 Oft• S_6 P V1
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-used wells ORLINER(if lip licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
ft. ft.
CompaayName 16.INNER CASING OR TUBING eothermal rlose3-loon)
2.Well Construction Permit#: FROM TO DIAMETER TMCIINrss I MATERIAL
List all applicable well construction permits r.e. C,County,State,Variance,eta.) -;-I tL it G I-c., rn. 5]:)R 31 P vc
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural MMunicipal/Public
❑Geothermal(Heating/CoolingSugply) Residential Water Supply(single) ft ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well D ft, �, ft. 14of C Pi PC,or,,I IS'kir' S
❑Monitoring ❑Recovery ft ft,
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK if a linable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(HeatinglCoolingRr°hnn) ❑Other(explain under#21?Rematic�) FROM TO D&SCRnMONcolor,hardness,soiVra rk 4 sin si:e,ete& LI� ft �p!f
4.Date Well(s)Completed: �® a 3 well ID#M P'J7 l ft SAL ft 6t`t
Sa.Well
►�Location: Phone # 2(43^a16-1107 ft: ft
h 5A M;/LI'W 124'al yo'1ko) ft ft
F Owner Name f- V Fa ID#(ifapphcable) ft. it
4-o E Y3 in(,1 >` "Ile- 334-,1104 543 ft. ft
Physical Address,City,and lip } �_ _
ft ft
2L REMARKS
County Parcel Men cation No.(P N) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(loagis sufficient) 22.Certification.•
N 71 S0, &1?d7 w c
6.Is(are)the well(s): Permanent or ❑Temporary Signatxe of Cdtified Well Contractor Date
By signing thisform,7hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *40 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction kiformalion and ezplai n the nature of the of this record has been provided to the well owner. ` t
repair under 421 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBIV=AL INSTRUCTIONS
9.Total well depth below land surface: �7 a'a (ft)
For multiple wells list all depths Ifdifferent(krample-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the f0]lowing:
10.Static water level below top of casing: &0 ( 24a. For All Wells: Original form to Division of Water Resources (DWR),ft.)If wafer level is above casing,use htformation processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+" /
11.Borehole diameter {� (in.) 13tt Off: 1 t.)� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY CK
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
VJ
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) ;5 Method of test: tv Permit Program,1611 MSC,Raleigh,NC 27699-I611 is
13b.Disinfection type: 70%HTH Amount: I ( OZ DATE SITE VISITED:- 11"1—2 11
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