GW1-2023-01825_Well Construction - GW1_20230223

CO I TS RUC 1�IBC N RE COR (GNV-1, For Internal Use Only:
1.Well Contractor Information:
rn tA 14.WATER ZONES
Wdl Contractor Name t PROM TO DESCRIPTION
62 S 1�� el
ft, ft
NC Well Contractor Certification Number IS.OUTER CASING for multi-ursed wells)OR LINER if a licable
YADKIN WELL COMPANY,INC. PR 7::ft.J�Tf,
ETER TEUCKNESS MATERIAL
in.
Company Name ^ ] 16.INNER CASING OR TUBING Peothermal dosed-too
2.Well Construction Permit U C� W FROM To DL+A:CETER •IMCICvrss MATERIAL
List all applicable x+ell cans4ruct/on pn'mits(ix-WC,County,State, Yoriance,etc.) ft ft in.
3.Well Use(ebeckwell use): ft. ft. in.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER SLOT SIZE THICfOYESS MATERIAL ,
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO IHAT-TRIAL EMYLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C it. ft.
❑Monitoring ❑Recovery ft ft.
Injection Well: ft ft —
[]Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a tumble) ,
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM To MAraRiAL EMLPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach add i tonal sheets if necessary)
FROM TO DESCRIPTION color,hirdnus,soil/mck ,, ain sb2'cuc
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) ft. —
4.Date Well(s)Completed: Well ID#mP— ft. ft
5a.Well Location:
Phone # fL ft _
�r-1 Chip 2 e ft. _r!r-Go h9 ft.�
Facility/Owner Name/ Facility ID#(if applicable) ft. ft
e.e YLlto.4, ft ft t .; 2 0 Z -
Physical Address,City,and Zip ft ft.
County Parcel Identification No.(PIN) 0 w
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ���cza S y1Lo Il 4-
(ifwell field,one lat/longis sufficient) 22.Certification:
3G 1�135! N Sl 041, tP5 W r
�k__k� ;--�-
6.Is(are)the well(s):ASPermaneut or ❑Temporary 5" re of Ce ed Well Contractor Date
By signing thisform,l hereby certify twat the well(s)was(were)constructed in accordance with
7.Is this a repair to an eldsting well: Ye or *0�ePP�+ ISA NCAC 01C.0100 or hA NCAC 01C.0100 Well Construction SYandards and that a copy
If this is a repair,fill out known well constructi ation and erplat3'the nature of the of this record has been provided to thi:we//owner.
repair under#21 remark section oron the back ofthisform.
23.Site diagram or additional Drell 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'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -M' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfd�erent(eromple-3(c�i 100'and 1©100)
�� ` 24a. For All Wells: Original :form to Division of Water Resources (DWR),
Ifwafer level is above casing,use "+" it.
f Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in) Bit Off: 5 940 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/ , j Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �1- ° Method of test: wt
13b.Disinfection type: 70%HTH Amount: r OZ DATE SITE VISITED:[`1'�Z 2' Vo2—
Pr i c--P• _ VISITED BY: Of
13`'Z(gh
Form GW-1 onmental Quality-Division of Wpr.r R esnorr.-s R...:­.1 F_A_-rrrr v