GW1--03082_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 11�� i
Serf!, �Q�M_1 r'S 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
/�
ft. J qo ft. y 4
a cL4 a7�A ft. ft. Io
0
NC Well Contractor Certification Number 15.OUTER CASING(far nmlti-cased.welLs)OR LINER(if,a licable)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS NUTERIAL
ft. ft in.
Company Name S4.6C�2 '3', lqoz
16.INNER CASING OR TUBING(geothermal dosed-Iao
2.Well Construction Permit# �®(o FROM TO DULNIETER THICKNESS 11L1TERIAL
List all applicable well consiniction permits#.e.U1C,Counry•State, Variance,etc.) I ft. r ft. 1/41 in. �DB PVC
� C,
3.Well Use(check well use): ft. J ft. to F V
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ®- ft. G, ft. 41t P a
❑Monitoring ❑Recovery 40 ft. 5' ft. (1ulck 6r&uli d
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a 'Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type rain size,eta)
Date Well Started .O ? An O ft. V rt. '/ 1
4.Date Well(s)Completed: . Well ID#�f3f's rj� ft. GOZ ft.
Sa.Well Location: Phone#JS( ft.
ft. ft. + .
nn�ae% VC��jj�©w-1--f
Facility/Owner Name VFacility ID#(if applicable) R• ft nM
2023
10!7.3 Mid 0*0
/!52 tsl 624J ft. ft. N G O
Physical Address,City,and ipr
IflfvfSst",.:ti:;^,il I'�f:'.!'Js;•FraF. 11 ��
B ps�e S 21.R�E-,�MCA/RKS,
County {s Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: #Loeps-p ) Dian O
(if well.field,one ladlong is sufficient) 22.Certification: S -
6.Is(are)the well(s): Rf ermanent or ❑Temporary Signakre of CIrtified Well Contractor Date
By sio ling this forin,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MT11. 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy,..
If this is a repair,fill out knowyn well construction information and 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 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 construction info
construction,only l GW-I 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: 60'a (ft) Submit this GW-1 within 30 days of well completion per the following: \ �®
For multiple wells list all depths ifdifferent(example-3 200'utnd 2©1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: see (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
® 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) t
11.Borehole diameter: (in.)) Ob Si -i 3 Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: VOAa C- 1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA/1 \
�y Permit Program,1611 MSC,Raleigh,NC 27699-1611 r I'J
13a.Yield(gpm) 4 Method of test: 41
° 5 A
13b.Disinfection type: 70�o hth Amount: OZ t �2 7
Form GW-I _ _-1lorth[terns '?'^" "'" -`��nmental Quality-Division of Water Resources Revised 6-6-2018
Price: