GW1-2023-01814_Well Construction - GW1_20230223

zL C�l�S1iTt�7�1T1I'�l�t -1'1 For Internal Use Only:
1.WCII Contractor Inforriantion:
y"I"'llt�1` - 14.WATER ZONES
P
Well Contractor Nam FROM TO DESCRIPTION7 1-
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased w OR LINER if applicable)
YADKIN WELL COMPANY,INC. FROM To DIANM-ER THICK SS MATE a
fr. ft. in.
Company Name -
16.INNER CASING OR TUBING(geothermal dosed-loo
2.Well Construction Permit#: 1 A 7._4�"3 FROM To DL/M1•:ER THICKNESS 114ATERSAL
List all applicable well construction permits(<.e.IU,County,State,Variance,etc) rt C It
.in.
to.5 oje% I C
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DLk=E II SLOT SIZE THICft1NESS MATERIAL
DAgricultural ❑MunicipalRublic it. fr. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATER1A], EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft'
❑Monitoring ❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, EMYLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft-
DExperimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) T
TO DESCRIPTION ent°r,hnrdness,s°Svrocic 4 Frain sae,ctc
4.Date Well(s)Completed:_/� �-}- Well D# �4( - tY �yQ`ft•5a.Well Location: Phone #104� 3o l t z 3 ft81W htGhGa E!hy ft
Fardli /Owner Name Facility ED#(if applicable) ft. ft
3 pt-w P V ft. ft -
Physical Address,City,and Zip As,/ ft ft. -
21.REMARKR
County ParcelIdentifcationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
N $f 39, 2B14� W � - k /_ �..�y
6.Is(are)the well(s): germauent or ❑Temporary Sign of Cerdfqywru Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an txisting well: ❑Yes or *0 15A NCAC 02C.0100 or 15A 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 ofthe of this record has beenprovided to the well owner.
repair under k21 remarks.eection or on the back of thisform.
23.Site diagram or additional well details:
B.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 n�ded, 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: 3t/© (ft.)
For multiple wells list all depths Ifdifferent(example-3@200'and 2Q100) Submit this GW-1 within 3D days of well completion per the following:
u 242. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: D (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use "+"
11.Borehole diameter: (in) Bit Off: .I a' 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:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinR over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) -.1 C Method of test: GLL�/i
Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH OZ DATE SITE VISITED: _` `LZ ��V r
13b.Disinfection type: Amount: -� Q r i`I
P r i rP- - VISITED BY:
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