GW1-2023-01820_Well Construction - GW1_20230223

I,v , -IN liTi�J� 1�'C1�I�I I�IE tC T➢ � �_V p For Internal Use Only:
1.Welt Contractor Informntion:
r^
c.)C A L, �6 ' s � 14.WATER ZONES
Well Contractor N e FROM TO DESCRIP
TION
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASIN multi-rased
G for ulsed wells ORLINER if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER ffi TCKNESs MATERIAL
ft. ft. in.
Company Name (�- ���L,j 16.INNER CASING OR TUBING ,eothermal closed-loop)
)
Ilk,
2.Well Construction Permit#: ®ls °�J{r FROM To DIAME CER THICICNrSS MATERIAI
List all applicable well co?rstruclion permits(1,e.UIC,County,State,Variance,etc) M (f ft I.• Jae
3.Well Use(check well use): ft. I ft. in.
17.Water Supply Well: FROATRELr TO DIAMETER SLOTSIZE THICICYESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
❑Industrial/Comrnercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD rltoM To MATEISAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 3 ft. �.`1-
[]Monitoring ❑Recovery a
/, rr.•,shirr r1'r-. �
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM 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(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To nEseRiP rlox �lor,s,ranes:,sosu�� e ,a:Qe,eta
4.Date Well Completed: �9�]3 Well ID#44
P- Z v z/4,ft' 3 c�it. -�5�:�f, �/��e .�eE•yls
5a.Well Location- Phone #q, tl� �C:'C7�� ft ft —
4
ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft.
Physical Address,City,and Zip fit
W ( (ems 21.REAIARICS _
County Parcel Identification No.(PIN) n'�•„i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) t� 22.Certification:
1100
6.1s(are)the well(s): lfermanent or ❑Temporary Signal erti% ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nKo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided/o the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.For Geoprobe/DPT or Cosed-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.SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: �7 - (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 r@200'and 2©100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
if- Static water level below top of casing: Y (ft.) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If woter level!s above nosing,use "+" _
11
•10�� 24b.For Injection Wells: Co
11.Borehole diameter: � (in.) Bit Off: py to D WR,Underground Injection Control(IUC)
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 dep&7tment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �' — Method of test: •.r �
c �, �'
13b.Disinfection type: 70/o HTH Amount: ��� OZ DATE SITE VISITED:
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