GW1--03080_Well Construction - GW1_20230428

Mma,CONSTRUCTION RECORD MV-11 For Internal Use Only:
1.Well Contractor Information:
14.WATERZONES
TROM TO DESCRIPTION
Well Contractor Name I ^ a
`;q ft. ft.
30344 ft $ ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells ORLINER if a lirsble
YADKIN WELL COMPANY,INC. FROM To D Tffira ClEss MATERIAI,
tt. in.
Company Name 16.INNER CASING OR TU13ING othermaIrlosr3-loo )
2.Well Construction Permit#: PR&UL2-a 2oG"C 9 FROM To I DI&KETTERJin.
Tfficramss rZtTtMAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,ela_) ft 9 1 ft 16 '� .D - _ Ve
3.Well Use(check well use): T ft ft.
Water Supply Well: rrROM REETo DTAMtTi - SLOT SIZE THICKNESS MATERIAL
❑Agricult oral ❑M�unicipal/Public ft,
❑Geothermal(Heating/Cooling Supply) Idesidential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Inigati0n ❑Wells>100,000 GPD FROM TO MATERUL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 6 ft' .24 f- /j 6/6.s 6
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft r 4P
❑Aquifer Recharge ❑Groundwater Remediation ti
19.SAND/GRAVEL PACK if a Ucable)
❑Aquifer Storage and Recovery ❑SaliaityBarrier FROM TO MATE RTAT' EKPLACEMENTMETHOD _ g
❑Aquifer Test ❑Stormwater Drainage ft-
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DR]I;L•IIVGLOG attach additional sheets ifnecessary)
❑Geothermal(Heating/CoolmgRetum) ❑Other(explain under#21 Remarks) FROM xo DEseRtPTION color,Laidaess,saiVrock n sae etc
ft. ft
4.DateWell(s)Completed: -.dam WeIIID i# "` ftd$
5a.Well Location: PIlOf1Er# ��-G�7_�- A/10�3 ft. ft.
S' � �s � 3�� &➢ O� ft it t �R�a�•'• sue.,
Ir
Famlity/OwnerNeme YR'ciay M#(if applicable)
ft. ft APR 2 b 203
Physical Addrrss,City,and Zip ft ft.
. 21.REMARKS /`f d!'r •.ro - °
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(i£well field,one lat/long is sufficient) 22.Certification: �Id 1 P�) 13W I. �
6.Is(are)the well(s): ldrmanent or ❑Temporary Signature of Certified Well Contractor 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: OYes or 3141 I5A NC-AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Randards and that a copy
If this is a repair,fdl out known we l construction Information and explain the nature of the of this retard has been provided to the well owner
repair under#21 remarkssection or on the backofthisform. 23,Site diagram or additionalweU details:
8.For GeoprobeMPT 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 if necessary.
drilled: •111, ��;� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '' (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Iist all depths if different(example-3()o 200'and 2©l00)
24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Statiewater level below top of casing: J (ft.) Information Processing UA 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above coring,use"-F"
Bit Off: 1 1 Ll 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
B FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Progratn,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / Method of test: �� gdd
13b.Disinfection type: 70%HTH Amount- oZ DATE SITE VISITED: A N ��' ��' pw
VISITED BY: �:.8 �$ �� �e+ak�t s `8� �B jll�'
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