GW1-2023-02223_Well Construction - GW1_20230307

" 'fU CONS 1TeUCTION IRiECORD(Gib-1i For Internal Use Only: zi
I.Well Contractor inforriintion:
F 14.WATER ZONES
�— FROM TO DESCRIPTION
Well Contractor Name
ft. fr. /60 60�
4 Sa 14 ft ft
NC Well Contractor Certification Number f'
15.OUTER CASING for multi-used weII0 OR LINER rf a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCKKEss MATERIAL.
ia.
Company Name /� 16.INNER CASING OR TUBING eothermal Closed-loop)
1
2.Well Construction Permit#: PR-JV . 2o2-Z®,,? 3 k3 FROM TO DIAMETER T111cm Ess afAnmL'-.
List all applicable well construction permits(r.e.WC,County,State,Yariance,etc) fr. 3R
it I Y rn• sDIt ' fo v
3.Well Use(check well use): ft fr. V in.
Water Supply Well: rROM E TO DIAMETER SLAT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) E esidential Water Supply(single) ft ft ;n
❑Industrial/Commeroial ❑Residential Water Supply(shared) is.GROUT
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: It. ft. 1�0�t P{.rr P y
❑Monitoring ❑Recovery ft fr.
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK rf a livable
❑Aquifcr Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E11ZPI.ACKNMNT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal CHeating/Coohng Return) ❑Other(explain under 021 Remarks) FROM TO DESMUPTION color,hardness,zaiVruck is sae etc
O (� y 0 ft ft. s
d.Date Wel(s)Completed: 07 I v 23 wd1ID# 'r F ft' lgg?R-
fL
5a.Well Location: Phone 9=-ZS I-7n 7 � ft. c
Facility/O Name F-lily ID#(if applicable) fr• fr'
uL Zk ft fL
eGn�
Physical Address,City,and Zip ft ft
21.REMARKS
—J rt^y
County ParcelIdentifiostionNo.UM4)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iffwlell field,one lat(loagis sufficient) a 22.Certification:
y
.X u 2�• qo N 9-4 .3.3, 7 S2 WQ-M-e�l
] ��
Sign of C ed Well Contractor Date
6.Is(are)the well(s): Aleermanent or ❑Temporary
By signing thisfarm,]hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or gR 15ANCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill oul known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under f21 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�IT-1 is needed. Indicate TOTAL NUMBER of wells (add Set Ovet in Remarks Box).You may also attach additional pages if neemary.
dulled: - (�tl 24.SUBMTrLAL INSTRUCTIONS
9.Total well depth below land surface: -1 8.) (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf different(example-3 a 200'and 2©1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: T� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
f Borehole diameter (in.) sit Off: •0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636 C
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(it.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
I3a.Yield(gpm) lob Method of test:/.^#l� S-�,k.-yr
/ DATE SITE VISITED: q-o-vZ
13b.Disinfection type: 7D c�HTH Amount: C OZ
'n-4 VISITED BY: fX7,