GW1-2023-02027_Well Construction - GW1_20230303

N '�L+C�I�TS 1JTe1LT�1T11'd�1�I C�11 (�r�I-1� For Internal Use Only:
1.Well Contractor Information:
6i"d 19,WATER BONES
We1lContractor Name FROM TO DESCRIPTION
ft. n j I Mf,d 1 Mwh � 'J+
I
NC Well Contractor Certification Number g9ft, ffb ft. i f� �. 9 6��j6�Il•�;�, y
15.OUTER CASING formuld-cased wells ORLWER Cifaplucable
YADKIN WELL COMPANY,ING. FROM To DIAMETER THICKNESS MATERIAL
• 1
Company Name 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: �5_I FROM To DIAPIZTER THICI NFSS N2ATERIAI,
List all applicable well construclion perm (J,a.UIC,County,Slate,T1arionce,etc) ft j„ �u' _PVC
e7
�e C'b I .
3.Well Use(check well use): ft ft. �s/r in.
Water Supply Well: 17.SCREEN
PP Y Rlg�.GROUT
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft,
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) In
❑Industrial/Comrrlercial ❑Residential Water Supply(shared)
❑irrigation ❑Wells>100,000 GPD TO MATMUAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: ® ft' J1 .
❑Monitoring ❑Recovery it ft.
Injection Well:
ft. t}
❑Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACE if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Storinwater Drainage B
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remaila) FROM To DES CRiPITOx color,hardness,mivrnck ain svt;eve
PP ft. ft.
4.Date Well(s)Completed: '' 1 Well ID# P-3�D ' r(Nni '
Sa.Well Location: Q /' Phone # fro-al ., SA0 100 fL `� ft V95. 1-= u •`� i'�' �/
IL.
Facility/0 erName R. ft I" -
�� ft. ft s
MA R S _. .,
Physical Address,City,and Zip
-foh k
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): kermanent or ❑Temporary Signature of C ed Well for Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.TS this a repair to an existing well: ❑Yes or 'No 15A NCAC 02C.0100 or 15A NUC 02C.0200 Well Construction ffiandarrlr and that a copy
If this is a repair,fdl out known well construction b7formation and explain the nature of the of this recordhas been provided to the well owner.
repair under 921 remarks section or on the back of thisform.
23.Site diagram or additionalwelI 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_G1Tir-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlm Box).You may also attach additional pages if necessary.
drilled:, [ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - d oo (ft.)
For multiple wells list all depths Ifdiffereni(example-3@200'and 2©100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: �® (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wafer level is above casing,use
11.Borehole diameter- (in,) Bit Off: �' 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 g
12.Well construction method: AIR ROTARY 1
2dc.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 3
(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,CCPCU
13a.Yield(gpm) 50 Method of test: `' Permit Program,1611 MSC,Raleigh,NC 27699-1611 V,
7o% HTH i OZ. DATE SITE VISITED: C
13b.Disinfection type: Amount: ®�
- VISITED BY:
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