GW1--03081_Well Construction - GW1_20230428

"a CONS 1 '1[TCT1ION 1L'�ITi+.CORD QW-1) For Internal Use Only:
1.Weli Contractor Inforn:ttion:
L— - /
lA.WATER ZONE,S P nr
Well Contractor Namel
FROM TO I DESCRIPTION
�a ,07' 36F.ft. r1%
ft it
NC Well Contractor CertiScationNumber 15.OUTER CA NU for multi-cased weIIs OR LINER if a livable
YADKIN WELL COMPANY,INC. FROM To DIANIILTER THICrOYENS MATERIAL sl
ft ft. in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-lao
2.Well Construction Permit#:_AR QILJ ��C�2 2®� t9 FROM TO DIAMETER THICIINESS MATIRIAL
List all applicable well construction pem its rl e.DIC,County,Slate,Yariance,etc) 11 % r 1 ft 46e g`
3.Well Use(check well use): ft ft in.
Water Supply Well: IT SCREEN
FROM- TO DIAMETER SLOT SIZE THICIMSS MATERIAL
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft., ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Su 1 Well: ft Aso ft
PP Y � 7 U
OMonitoring ❑Recovery P e it
Injection Well: 7 `9 1 ft.
❑Aquifer Recharge ❑Groundwater Remediation ft. fL
19.❑Aquifer Storage and Recovery ❑Salinity Barrier rROM xo SAND/GRAVEL PACK D a livable
FR IIIATERIAL EnTPLACEIVIENTMLTHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑ m Geotheral(Heating/CooIing Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soitfrocklype,grain sae,cte
ft. O fL ®I�
4.Date Wells)Completed: Well IN 4P� ®• ft eW `' `4
.Are f ,-&
fL it
5a.Well Location: Phone y /
-J c0a -V.
ft. ft
Facility/OwnerName Facility ID#(ifapplicable) ft ft (•.� +�f '^1
� ft ft
Physical Address,City,and zip A 4
21.REMARKS
County Parcel Identification No.(PIN) Tit ca i( G y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
6.Is(are)thewell(s): OPermanent or ❑Temporary Sign eof CerfifirdWellContractor Date
By signing thisform,l hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15ANC,4C 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and That a copy
If this is a repair,frtl aul lamwn well construction infarmation and erploin the nature of the of this record has been provided to the well owner
repair under#21 remarks section or on the back ofihisform.
23.Site diagram or additional well details:
8.For Geoprobc/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 if necessary
drilled:
24.SU.BMr TALINSTRUCTIONS ��
9.Total well depth below land surface: 3 q,(ft.) ��
Submit thi GW-1 within 3D d s of well cam letion e
For multiple wells list all depths ifdifferend(example-3(a)200'and 2@1009 s aY p p r the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
if wafer level is above casing,use"+"Static water level below top of casing: �� (ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If
IL'Borehole diameter- (in,) Bit Off: %® 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
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 d1
(ie.auger.rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinRr over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) rS Method of test:_ d Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: z;L s OZ DATE SITE VISITED:�
VISITED BY:
psis-a.,- - ---- - ---- I