GW1--03062_Well Construction - GW1_20230428

WtL C-, Sl1iT�'1UJCi11ION i��WORD(sGW— For Internal Use Only:
1.Well CoritrQacror In-sor[antio�n:
14.WAT RZONES
Well'ContractorName FROM TO DESCRIPTION
ft. ft.
NC Well Contractor-Certification Number
1s•OUTERCASING for multi-casedwelis OR LINER rfa licable
YADKIN WELL COMPANY,INC. FROM xo JAMETER THICKNESS I MATERIAL
ft. R: in.
Company Name
/ 16.INNER CASING OR TUBING(panther closed-loon)
2.Well Construction Permit#:_Q 1 Z ��1 - Z��( FROM To DIAMETER TZiIClairss MATERIAL,
List all applicable well construction pernits gx-UIC,County,State,lrariarrce,etc) ft v ft. ill. v` +o y 1 �Z�+y
3.Well Use(check well use): ft. ft. in. J J�
Water Supply Well: 17.SCREEN
IItOM TO DIAMETER SLOT SIZE THICIQNESS MATERIAL
❑AgriculturaI ❑MM�unicipal/Public
❑Geothermal(Heating/Cooling Supply) liKesidential Water Supply(single) ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERUL EMSLACn ENT114LTHOD&AMOUNT
Non-Water Supply Well: ft• ' ft. f ch t V-GdV,'.,
❑Monitoring ❑Recovery & ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19•SAND/GRAVEL PACK iia ueahie)
FROM I TO I MATERL&L Eh7PLACE=i NTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) []Tracer 20,DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM To DFS oN �mr natdnesa,sovroek a .in sv2 ec�
f ft `>01
4.Date Well(s)Completed; C Well ID#A A19"J V 7 ft• ft �P �1" _
5a.Well Location: t`r c ft.
Phone # 3G� zt;2-UGQ7
�� �j ft ft `tea
Facility/OwnerNIne FadlityM#Cif applicable) ft ft.--
204 1 44 (i9�/Lc+l L� ft. �
APR
Physical Address;City,and Zip ft fti
/ GQ k�� 21.REMARKS
County . Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Xviell field,one lat/longis sufficient)
22.Certiflcation:
�" Certified Well Contractor
/ " - .
6.Is(are)the well(s): Nil ermaneut or ❑Temporary Date
By signing thisform;I hereby'certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 13A NCAC 02C.0100 oe I5A NCAC D2C.0200 Well Construction Standards and that a cW
If this is a repair,fill out known well construction information and explain the nature of the ; of this record has been provided to the well owner.
repair under#2l 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 donstruction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlcs Box).You may also attach additional pages ifnecessary.
drilled: f '1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `�u.� (ft.) Sbmit this GW-1 within 30 days For multiple wells Iist all depths lfdierent(erample-3Q200'and 2©100) u Y of well completion per the following: (�
10.Static water level below top of casing: 5 0 (ft.) 24a• For All.Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing use"+" , + Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
: 24b
F .For Injection Wells:
11.BorehoIe diameter: co (in.) Bit Off — T Copy to D WR,Underground Injection Contiol(lUC)
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(io.auger,rotary,cable,direct push,eto.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i county environmental health department of the county where installed
FOR WATER SUPPL
Y WELLS ONLY: o ® 24d.For Water Wells producing over 100,000-GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) eTi Method of test: A l l' Permit Program,I61I MSC,Raleigh,NC 27699-1611
� ca
13b.Disinfection type: Amount:
70%HTH OZ DATE SITE VISITED:
Pr i -- - - --- - VISITED BY: