GW1-2023-01821_Well Construction - GW1_20230223

I RECORD f GW-1) For Internal Use Only:
1.Well Contractor Information:
.�e�( .1 (,A-) CI✓1 14.WATER ZONES
FROM TO DI:SCRIPTION
Wcil Contractor Name
aySa•� ft. AND ft. 3 ErPM
NC Well Contractor Certification Number IS.OUTER CASING for multi-r�si�Wells OR LINER if a linable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNEss I MATERIAL
Company Name 16.INNER CASING ORTUBWG geothermal closed-loop)�..�
FROM TO DIAMETER TffiCISZVPSS ]1SA7TRTAr
2.Well Construction Permit#: Ei w
List all opplicable well construction pumits(r,e.UIC,County,State,Variance,etc.) t I ft. ( t It
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN _
FROM TO DIAML-Mi SLOT SIZE THICKNESS MATERIAL
❑Agricultnral ❑/unieipal/Public ft. ft, E3,
❑Geothermal(Heating/Cooling Supply) 12sidential Water Supply(single) ft. ft. iI.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 011. ft' 140le P b SS
❑Monitoring ❑Recovery it ft.
Injection Well:
[]Aquifer Recharge ❑Groundwater Remediatiou -
19.SAND/GRAVEL PACK(if arable)
[]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 nevessa
, Deco thermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM TO DFSCP]T7IONcolor,hardness,soiVrocke,grain size,etc
-
p ft. /do It.
4.Date Well(s)Completed: Z Cr a3 wcuim (X 120 ft. 340 ft-
ft. ft.
5a."Well Location: Phone #3�G= ���'����'
P�1K �_�- f. ft -
Facility/Owner Name /�FacilityIDA(ifJVplicable) ft. ft -
j 0 K w le.l M G5 C_10 CIA/"� e� / �`t✓1 ft. ft
.� -7 � ft ft. •�
Physical Address,City,and Zip a�Z�
21.REMARKS
County Parcel Identification No_(FIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwellfield,one lat/longis sufficient) 22.Certification:
'Ir19 671 N kD J-9, 2� 3 W 21(. 33
6.Is(are) the well(s): C+?Permanent or ❑Temporary Signatn of Ce cd Well Contractor Date
�/ By signing thisform,I hereby certify that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �INo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Fell Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the we!l owner.
repair tinder f21 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 iftcoessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3y0 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3 c@200'and 2©100�
30 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use "+" _
Bit Off: � t 1 p
4 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: C.-2 (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 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
^ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: h�1(' (a J/
70%HTH Amount: oz DATE SITE VISITED:
13b.Disinfection type:
1
Pri r,P: VISITED BY: .4
n,..,.•r.W-1 'onmental Quality-Division of Water Resources Revised 6-6-2018 Z