GW1--03077_Well Construction - GW1_20230428

WELL =---CONSTRUCTION 1E'C (GW-2.) For Internal Use Only:
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1.Well Contractor Inf Jorrantion:• ec -1 • Wa.(•,k c AS 14.WATER ZONES V).----
Well Contractor Name FROM TO DESCRIPTION
o7y�.� ft. 332 ft. !d0 Gymft. ft.NC Well Conhactor CeutilicationNumber15.OUTER CASING(formniti-rased wells)WILINER(if ap[�limbic)
YADKIN WELL COMPANY,INC. PROM TO DIAMETER THIC MESS I MATERIAL
Company Name ,I„I ft' e0f G 1�41in. 5Dt7I PVC.
:rlei,- ' ' f` t^' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:( fa�L 20 2.2 0(,y 7 6 FROM TO DrUtirrrEv 'rmci ss MATERIAL
List all applicable well constructian permits(ce.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): /ft. �in.
Water Supply Well: 17./SCREEN //
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ❑, M/unicipal/Public 2,,, ft. iu.f i
❑Geothermal(Heating/Cooling Supply) 6Residential Water Supply(single) ft. ft wit( ` / -
❑Indust ial/Commercial DResidential Water Supply(shared) Th.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: 0 ft 3 ft: «dleet s, &hired .2 isects
DMonitoring DRecovery it g f
Injection Well: 3 ?$ awe cei. Pamirs 3 b '
:Aquifer Recharge ❑Groundwater Remediation
19.SAPID/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Ea1LArr vrr+NTMLTHOD
DAquifer Test ❑Storrnwater Drainage
❑Experimental Technology ❑Subsidence Control - ® it /
❑Geothermal(Closed Loop) ❑Tracer --- t 1, 1 20.DRILLING LOG(attach additional sheets if necessary)
I - - ' - - FROM TO DESCRIPTION(color,hardness.eol/rorktype,grain size.etc)
❑Geothermal(Heating/Cooling Retain) #L) ❑Other(explarnimder -Remarks)
',---, b ft 7 y ft Sat I
4.Date Well(s)Completed: 31313''3 Well ( PtP ' t5UL I ,i 711
7 ft. Sys ft 6MIArtft.
5a, /WellLocation: Phone #�` g - 779_.,4,5'�- ft.
• /P!'11 e l ! r C ie TJE^ f. ft.
l-J
Facility/OwnerName /� Facility ID#(if applicable) ft. ft -,-.� - N�^ f '`4
) iS ✓ I_r ( /-i'/b'i' �4f, 270 S l ft ft. f :
Physical Address, and Zip f. f<. H r R G 0 [U23
es
@J V"II�V 21.REMARKS x,-
Y n 4r r ....., r'r.- - ter. ....
County Parcel Identification No.(PIN) :-1 0,.30c.: �� 'h�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
.31 4 26'22.' N RO p 6-3 2,5e W
w
�� aotPk 3 t°2,P3
6.Is(are)the well(s): Permanent or OTemporary Sign a of C rlified Well Contractor Date
By signing thisfann,Thereby certify that the wells.)was(were)constructed In accordance with
7.Is this a repair to an existing well: DYes or IgNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Mandards and that a copy
If this Lea repair,fill out lmown well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair wider f21 remarks section or on the back of this.forye.
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 I GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Sy S (ft) Submit this GW-1 within 30 days For multiple wells list all depths If different(example-3(a)200'and 2@100) of well completion per the following: �
24a. For All Wells: Original form to Division of Water Resources (DWR), ��
10.Static water level below top of casing: ft (D )
Ifwater level is above casing,use"+"® ( ) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ` (in.) Bit Off: S,fit its. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY \
(ie,auger.rotary,cable,directpush etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the c�l� I
county environmental health department of the county where installed V>_
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR, CPCUA i
Pennit Program,1611 MSC,Raleigh,NC 27699-1611 1e�ei,l 4- I'
13a.Yield(gpm) 100 Method of test: Rt r
70%HTH° OZ DATE SITE VISITED: --2$ Z 2- is �,i£. n "
13b.Disinfection type: Amount: a2 � N`�
VISITED BY: Q1
Form .. ..,..,n,.-r:... na.:----r.,._._ ,. -. -