GW1--03112_Well Construction - GW1_20230428

-CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JCA rN1(1 I.. 14.WATER ZONES
PROM TO DESCRIPTION
Well Contractor Name 90' y O /S a,,,
NC Well Contractor nNumhc C 6 .•-. 647 ft s- q �7`+' - 8 I " 7®7 1 Al15 0D1ER CASING•(for multi-ce wells)ORLINER(if ap linable) I
YADKIN WELL COMPANY,INC. PROM TO _DIAMETER THICKNESS 1 MATERIAL
ft. ft. in. ,
CompanyName IX- 7 3-t i i-. 16.INNER CASING OR TUBING(geothermal closed-lamp)
�'ol�' PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3 4."�. � T / l�
List oil applicable well construction permits a UIG County,State,Variance,eta) �/ ft7�i ft 6,/3r in. ay..�., Pit
ft3.Well Use(check well use): ft. in.
Water Supply Well: l7.6CREI N
pp y ITtoM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) I74sidential Water Supply(single) • ft ft in. "
❑Industrial/Commercial . ❑Rcsidertial Water Supply(shared) H.•GROUT
❑Inigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft ".� fW 4el
❑Monitoring l7Recovety q. ft 9 it. ed4.4 fills`' l eci /,emor
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage • ft ft.
❑Experimental Technology DSubsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness.wi/rorxtype Brain Dist,etc)
s+o,�- a-'1.z3 ry P--2o1 ° S ` oeL
4.Date Well(s)Completed: J 'IV'a.? Well ID# A r� �-P ft. geArft ArriAirScrdrili Ve
5a.Well Location: Phone #33-23,3-/&fC y1( ft sboa ,n W-Y7 P'r71*a
L 1 s �i tram ft. ft
Fam7ity/OwnnerName y Facility IDii(if applicable) ft. f.
�
�'7 tt j ea1g iac.(U(d'i i`t ft. it - , - ; V i--fr
Physical Address,,Cfly,and Zip ft ft. u'` b !�^^
21.REMARKS f.UL3
County Parcel IdentifioationNo.(PIN) "41Prr- f_7,-;„r„;;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): Blfermanent or' ❑Temporary 5igo of Certified ell Contractor Date
By signing thisform,Thereby certify that the wells)was(were)constructed in acrerdmrce with
7.Is this a repair to an existing well: ❑Yes or &lei 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
yells
is is arepelr,fill out]mown well construction btformatlon and erplaln the nature of the of thts record has been provided to'helve!!owner.
repair underl21 remarks section or on the back ofthisfonn. 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 G -1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: • 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ROO (ft) I
For multiple wells Its!all depths If different(example-3(aj200'and 2®100')
Submit this GW-1 within 30 days of well completion per the following:
a'
10.Static water level below top of casing: lid ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaterlevel is above casing use"+" �p
C Bit Off: 3:7 07 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: O 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
(ie.auger,rotary,cable,Skeet push,etc.) county environmental health department of the county where installed (.,
FOR WATER SUPPLY WELLS ONLY: QQ 24d.For Water Wells producing aver 100,000 GPD:Copy to DWR,CCPCUA
95.
Method of test: :lr/Ldy Permit Program,1611 MSC,Raleigh,NC 27699-1611 U
13a.Yield(gpm) \
13b.Disinfection type: 70%HTH Amount: 31 OZ DATE SITE VISITED: R. 26
I VISITED BY: O