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Home My WebLink AboutGW1--03083_Well Construction - GW1_20230428 ,..� _ _ S .. ligi al., NSTR1UCJi'ILON R.l]"drOO A(GTV-1) For Internal Use Only: 1.Well Contractor Information: 7`F &IA/ Zero)ki L 19.WATER ZONES 10 C....i Well Contractor Name FROM TO /DESCRIPTION 3® � 6 A 170 ft. 171ft. 4 Li - Ill d15'5(- NC Well Contractor Certification Number 3 i�f t' 34^ f t' 'F,� �,® Zj 15,OUTER CASING(oIti-cased wells)QR LINER(if ap licable) YADKIN WELL COMPANY,INC. FROM DIAMETER THICKNESS MATERIAL Company Name ft �� in. ' � 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: FROM TO DIAMETER TffiCIGNESs MATERIAL, List all applicable well construction permits(i.e. C,County,State,Variance,etc) "I- L j ft L g ft. '�t' in. 11 �. s 3.Well Use(check well use): �� 1 2' `v�Te�� ft ft. in. il Water Supply Well: . 17.SCREEN ❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL unicipal/Public ft, g, in. ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) / t. ft. in. J ❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑Isigation18.GROUT .-- ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT Non-Water Supply Well: 0 ft P S ft A//,. � �1 t. 4 p p ri ❑Monitoring ❑Recovery ft ® ft /I/ A�i (uN f� Injection Well: ❑Aquifer Recharge ❑Groundwater Remediation ft. 1t- ❑Aquifer Storage and Recovery ❑ga]inity Barrier19•SAND/GRAVEL PACK(if applicable) - ❑Aquifer Test FROM TO _ MATERIAL _ EMPLACEMENT METHOD ❑StonnwaterDrainage ft. ft ❑Experimental Technology ❑Subsidence Control ft ft ....0''� __./ `/. ❑Geothermal(Closed Loup) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) ❑Geothermal(Heating/CooIingRetum) ❑Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sloe,etc.) �L. ft ft �� ,-Si e i 4.Date Well(s)Completed: i ''�� WeII�D!1 AA ` s g ft s s- ft hkud , ��,- c k r 5a.Well Location: /� T',S'ft 176 ft ,fp 1$11P4 u 3 �J�le, F Phone #33C.��'-��y� 1 X. PA,e� „., o,�a(uist�Qn.4 WI,iI _rerIc T 170 3I4 1-LJ 6r n/(1-e.s Facility/OwnerName Facility ID#(if applicable) J. ft 0 ft KiN / „TOP.. ife.kJ ev ` AI lel ate- B re...)'i-e2Ili 01(4- 701, ft. 5 '' _ft .U-t-v-c >',,A.ve;9`i Physical Address,City,and Zip ft. ft ��TCt n ��h^ '' " e Ls fl.®o V L. y 21.REMARKS County Parcel Identification No.(PIN) al g --e 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A ; ��2? (if well field,one lat/longis sufficient) �O i�rC�c,S+is af�l)fi'f 22.Certification: (RFOrprair M a %( 4 yza N 77" Ya_ 3�v 67,1 --/ ga6g W ----:/ c�pra�'x d �4 , 2 -16 -3 6.Is(are)the w L1 ell(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date By signing thisform,l hereby certify that the wet/(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: [Wes or !lNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,fill out known 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 1 GW I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. --- drilled: i 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 5-0,; (ft) For multiple wells list all depths ifdfferent(example-3@200'and 2Q1009 Submit this GW-1 within 30 days of well completion per the following: 10.Static water Ievel below top of casing: s �d (,) 24a. For All Wells: Original form to Division of Water Resources (DWR), Ifwater level/s above casing,use"+" ®t jigr� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter: 1 t f o S ea'�1' Bit Off: �° � � 24b.For Injection Wells: to (in.) 1 Copy DWR,Underground Injection Control(IUC) AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636 (L12.Well construction method: 24c.For Water Supplyand Open-Loop Geothermal Return Wells:Copy to the e.auger,rotary,cable,direct push,etc.) p 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 13a.Yield(gpm) I lib Method of test: al Permit Program,1611 MSC,Raleigh,NC 27699-16I1 13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: ,�\rg‘. Pri rP_ VISITED BY: AlForm GW-1 r�