GW1--03069_Well Construction - GW1_20230428

��'a L CONSTRUCTION RECORD(GW-i,I For Internal Use Only:
I.Well Contractor Information:Oa)/ 14.WATER ZONES
� L.R.
I
Well Contractor Name FROM TO DESCRIPTION
415(95 FM ft. )••�i "- SO' (,P1\ City
NC Well Contractor Certification Number ft.
J ft
15.OUTER CASING•(for multi-cased wells)OR LINER(if ap linable) lib.
YADKIN WELL COMPANY,INC. FROM TO tl.DIAMETER ( TRIM:WEss MATES
Company Name ft in.
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 3 6,CO 3 5 FROM TO DIAMETER .TBICE:NESS MATERIAL
List all applicable well construction permits(ix.MC,County,State,Variance,etc) IL" ft 163 ft la in. ic, xi _�1
3.Well Use(check well use): C ft. lip
ft. in.
Water Supply Well: 17.SCREEN
❑Agricnitural FROM TO DIAMETER SLOT SIZE THICIa 1ESS MATERIAL
❑Municipal/Public ft. ft, in. II
❑Geothermal(Heating/Cooling Supply) pResidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial OResidential Water Supply(shared)
❑Irrigation iB.GROUT �.
❑Wells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: 6 ft gg�� }� &AMOUNT
❑Recovery - ft - 1 �vli B �'i~i•
ft. ft.
Injection Well: •
1 �0
uifer Recharge ft ft. 10.
❑A
q g ❑Groundwater Remediation
D.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑g
alinity Barrier FROM TO MATERIAL
❑ uifer Test E11�LACEMI NT METHOD
❑StDrmwaterDrainage ft. it
❑Experimental Technology ❑Subsidence Control ft. ft.
I' ' ❑Geothermal(CIosed Loop) OTracer • 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Coolmg Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(calm.hardness,sail/rack 1 type,grain sae,etc.)
.4.Date Well(s)Completed: 3-9-Xy Well ID# p.'Z.$12 1t7). ft. I .' ft g run (,E.n tir,�• et r r p,r) .
5a.Well Location: Phone # <,�Ie-a7)3-�l(l �I ft I�A. ft -�rir9r
_ -
ft SIB f_ci c1., Cw: 'IaJ cv if k - 6.g 12 21 , o.d"t_•- --- ,Facility/OwnerName FacilityiD#(if applicable) ft ft j. aii ,
ft
p c nil;i of ft
Physical Address,City,and Zip ft O
/ es ft. APR �E2,,
t'1 14��Gt� 21.REMARKS Intori- of i)t':4:ar"„,:r•;) IIn�4'
County Parcel Identification No.(PIN) CipJ(a:3'2 .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . . l
(if well field,one lat/long is sufficient)
22.Certification:
I. 3'1' N ? l 3r..6 elS2 w e.„ -
6:Is(are)the well(s): permanent or OTemporary
Signature of Certified Well Contractor Date
9 9.� `"
By signing thisform,I hereby certti,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I°rg'Qo 15ANCAC 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 aid explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of(his form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having tiie 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 if necessary.
drilled:
a 24.5UBIVIITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 L1 , (f)
For multiple wells list all depths([d Brent(example-3( 200'and 1p100) Submit this GW-1 within 30 days of well completion per the following: ral
N l
10.Static water level below top of casing: ) 24a. For All Wells: Original form to Division of Water Resources (DWR), '
Ifwater(evens above casing,use"+" (f t' Information Processing Unit, MSC,Raleigh,4(45
NC 27699-1617 j
11.Borehole diameter: 6, (1,•) Bit Off: 5° 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
(i12.Well construction method: Supply24c.For WaterOpen-Loop Geothermal Return Wells:Copy to the
.e.sugar,rotary,cable,direct push,etc.) and p I oo p
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm) 5®
24d.For Water Wells producing over 100,000 GED:Copy to DWR,CCPCUA
Method of test: Q r+v Permit Program,1611 MSC,Raleigh,NC 27699-I611
type:
13b.Disinfection 70%HTH -J 3 2.L
' Amount: OZ DATE SITE VISITED: G