GW1--03011_Well Construction - GW1_20230306

VV k,d L CONSTRUCTION iRE CORD(GW-1 c For Internal Use Only:
,L.V :,-�"zontractor Information:
�. �•��^�[ S 14.WATER ZONES
TI
Well Contractor Name FROM TO DESCRIP ON
ft. 3`eft. (;Pt7re
ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells ORLINER If a lieable
YADKIN WELL COMPANY,INC. FROM xo DIAMETER THICKNESS MATEMAL
ft. ft. in. -�
Company Name
16.11VNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#' ° °� FROM TO I)L" ER Tmcmrss TjA'ITR7AT.
List all applicable well construction permits(t.e,IUC,County,State,Variance,eta) 41 � t it YCIt in. vG
3.Well Use(check well use): ft ft. in.
Water Su Well: 17.SCREEN
Supply FROM I TO I DIAMETER SLOT SIZE THICIINMSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In•
[]Geothermal(Heating/Cooling Supply) rResidential Water Supply(single) ft. ft. in.
❑Iudustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 1
[]Irrigation ❑Wells>100,000 GPD FROM TO MATERML EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. L� tt.
❑Monitoring ❑Recovery it ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf a Iicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ER1:PLACEMENTM1=OD
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRnJMGLOG attach additional sheets if necessary)
❑Geothermal(Heating/CooBng Return) ❑Other(explain under#21 Remarics) FROM To DESCRIPTION color,hardnm,s°iVroek .•e, n svl,eta
,�y D it 100 ft. :50 c
4.Date Well(s)Completed: a 3 Well IN AA 6 / QQ R' t-?2ft' G can 3
5a.Well Location- Phone #��� �o-:26 ty ft ft.ft
ft �- '�,• _ __
ft.
Facrlity/OwnerNm ae Facility IDA(if applicable) ft "
ft MAR
Physical Address,City,and Zip rgf'11 f e A P-r ft #t
21.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(kfwell field,one lat/longis sufficient) 22.Certification:
W n rA)
6.Is(are)the well(s):Permanent or ❑Temporary Siga e off C ed Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or AND 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and arplain the nature of the of this record has been provided to the well owner.
repair under ill 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 ifnecessary.
drilled:, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ll (ft') Submit this 6t=ffwlthkn 30 days of well completion per the following:
For multiple wells list all depths lfdifferent(example-.5@200'and 2©700D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:_�_ 2 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
7fwater level Is above casing,use•'+" L o 0$ 24b.For znjection Wells: Copy to DWR,Underground Injection Control(lUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
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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
. -a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water WeIIs producing over 100,000 GPD:Copy to DWR,CCPCUAY,
Permit Program, MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: .4°�•
70 HTH OZ DATE SITE VISITED: 1® -2 G-,2 \�
13b.Disinfection type: °/° Amount: �3
----- -- - -- VISITED BY:
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