GW1-2023-01824_Well Construction - GW1_20230223

L C ONSTI RUC 1TI+ON RECORD(GW-1) For Internal Use Only: r�
Q
1.Well Contractor In--rormntion:
11
14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
,�/ ��� 1' 1 It.
, b 15
ANC Well Contractor Certification.Number U R t
5,OUT&R CASING for multi-used webs OR LINER ifs livable
YADKIN WELL COMPANY,INCH FROM To nlAMMR THICKNESS MATERIAL
Company Name i� � -�''LT C-f �' m' U L
//yy 16.INNER CASING OR TUBING eothermal dosed-loon)
2.Well Construction Permit#E: Va5�9 3 FROM TO DIAMETER THICIC%?US I MATERIAL
List all applicable well construction permits(ie,EUC,County,State,Variance,eta) % ft in.
3.Well Use(checkwell use): ft ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE TEXIMSS MA 'Al
❑Agricultural ❑M icipal/Public ft. R. in.
❑Geothermal(Ileating/Cooling Supply) sidential Water Supply(single) ft g, in.
❑ludustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
01ni 'on ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD& UNi
Non-Water Supply Well: ft. ft. r 4LC
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Cxf applivable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPIACEME+NT METHOD `
❑Aquifer Test ❑Stormwater Drainage ft R'
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessary)
07 3eothermal(Heating/Cooling Return) ❑Other(explain under#21 Rem Ics) FROM TO DESCRIPTION color,hardneas,SORImck a see,etc
It
o C)LLkl
4.Date Well(s)Completed: - Well ID � ft.
ft �� C P
ft
5a.WeHLo//c��ation:-r/j`//'3f3' Phone # �W�jt7 z
1 (..i'lYIL9'T�•aes� � ' /�' ft ft
Facility/Owner Name Facility IO#(if applicable) ft. ft
3 fK •,, ft ft
Physical/Addmss,City,and Zip ft. ft l r_
'e ,i 1 21..RREMABKS di
County Parcel Identification No.(PIN) `"'
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certific 'on:
J 7 /2. �-3 3 N ` J- ), 16 -7
6.Is(are)the well(s): permanent or ❑Temporary of Certified Well Contractor Deft
By signing th Ufa rm,I hereby certify that the we11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l(o 1 SANCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction.Standards and that a copy
If this is a repair,fdl out known well construction uiformation and erplab"the nature of the of this record has been provided io the well owner.
repair under#21 remarks section or on the back of thisform.
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 G�1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'inRemadcs Box).You may also attach additional pages if necessary.
drilled: 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ^ (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If diferent(example-3@200'and 2Q1000
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing use 1".
11.Borehole diameter: (in,) Bit Off: s 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,rotary,cable,direct push,etc.) county environmental health department of the county where installed
o�
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 LA13a.Yield(gpm) _ Method of test: s� 1 _ �;;�' •r�`",�� -�
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: /` "2-Z �e
Pri nP
VISITED BY: 6�
: -