GW1--03119_Well Construction - GW1_20230428

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NO--If;CONS lI CTION�L 1ECOJ1�Te' :(GW-11 For Internal Use Only:
=!Welt Contractor information: - ,
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"(� Vtt ° 14.WATER ZONES
- !`FROM • TO' `DESCRIPTION'
Well Cantiaetor Nam i t. : ft g"
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as`�)-`A l ft ft
NC Well Contractor Certification Number 15,OUTER CASING(for multi-eased sveps)'ORLINER of up livable)
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YADKIN WELL COMPANY,INC.• FROM TO -DIAMETER THICKNESS MATERIAL 4
ft . ft in. a I
CompmryName i} , / 16.IN INNER CASING OR T[IBING,(Reotherm 1 lased-loop).
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2:Well Construction Permit# OG ggp`', , PROM TO DIAMETER ` 'rfficr SS MATERIAL
List all applicable well construction permits(i.e.DIG County,State, ariance,etc) ft. ft/ 75- ' 1.0-).- in. sof a L f vc-
3:Well Use(check well use)e
17.SCREEN
, Water Supply Welt .,; ,._FROM TO DIAMETER SLOT SIZE THICttNEss MATERIAL !•
°Agricultural ❑M�unicipal/Public 'ft. ' 'ft to
pGeothermal(Ht ating/Coaliag Supply) �ICesidential Water Supply.(single) ft. .in.
❑Industrial/CommerciaI' ❑Residential Water Supply(shared) is.:GROUT
❑Wells>100,000 GPD :' ,BROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ,, -
Non Water Supply Well: ;_ 0 ft g ' ft. aen-el* Poore f
DMbnitoring ' . ; • ❑Recovery 3 A 24-` • or porN1.6,1 5.
Injection Well: . _
❑AquiferRecherge ❑GroundwaterRemediation 19.,SAPID/GRAVEL PACK(if applicable)
❑ACprifer Storage and Recovery ❑5almity Barrier FROM TO MATERIAL EMpLACEI1MITMETHOD _
°Aquifer Test . • OStormwater Drainage ft
❑Experimental Technology °Subsidence Control ft' ft
❑Geothermal(Closed Loop) °Tracer , 20.DRILLING LOG(attach additional.sheets➢fnecessary)
I `FROM ' TO DESCRIPTION:(eclar,hardaea,solllmektype,gram size,ate.) SSS'��
❑Geothermal(Heeting/CoolmggReturn) ❑Other(explain under#2'1Remarks) ® / 3, c'O l// / t
'"d.Date Well(s)Completed:. 7 -��)s WellIDPAA Z'2-Z. ' : . f� ft_ J df'/4/�'( i..re`1 �;
1 r..i.k 3',12_en,..tr t fi. ft
5a:'WellLocation: • . Phone #, C 4t44 270c -- r %
ft. ft. I. '
Facility ID#(if applicable) ft ft
Fa�itylowaerxame APR 2 b 2023
ft ft.
a,,4ez g.�,g. (Oar. .Spar ft ft lnioflr�Is:an isr:r�s�r lJnst
Pliysicai Atliimis,City.and Zip 21.REl1fARKS G"v"JLI�3
4ll e5 a ja Y!3'`/i z� L�rmc iL Rae.1� : 0.k.
Parcel Identification No.(PIN) :
5b.LatithaeJand longitude in degrees/minutes/seconds or decimal degrees: . , .
(if well freld,onalit/lanais sufficient) 22.'Certification:
L.
N /
6:Is(are)the well(s): Cam' ermanent or ❑Temporary
Si a of Cd:t Ed Well Contractor Date
I By signing thisform„I hereby cerii9 that the well(s)was(were),constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or Ito 15ANCAC 02C.0100 or!SA NCAC 02C.0200 Well Construction Standards and that a.copy
If this is a repair,fill out brawn well conshvdian in ormation and explain-the nature of the of this record has been provided to the welhowner. \�
repairundertlZl remarks section or on the back ofihisform. 23.y�,diggram or additional well details:
B.For Geoprobe/DPT or Closed--Loop Geothermal Wells having the same You may use the beck of this page to provide additional well construction info
910
construction,only 1 GW-1' needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional if necessary
-drilled: a 24.:SUBMITTAL INSTRUCITONS
9.Total:well.depth below land surface: 3?) (ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(=ample-3@200'and 2®1001
10.Static water level below top of casing: Ye
1 24a. For All Wells: Original'form to Division of Water Resources (1)WR),
(ft) Information Processing Unit,1617'MSC,Raleigh,NC 27699=1617
Ifwater level!saber casing,use"+",
(�•) Bit Off: ��Eset��'�'' 24b.For Injection Wells:Copy to DWR,Underground`Injection Control(IUC) I
11.Borehole diameter: �• Program,1636 MSC,Raleigh,NC 27699-1636
- AIR ROTARY
12.Well constructron.method: 24c.For Water Supply and Open-Loop•Geothermal Return Wells:Copy to the
(i.e.auger,rotary_cable,direct push,etc) countyenvironmentalhealth department of the county where installed
CA
FOR WATER SUPPLY WELLS ONLY 24d.For Water Wells producing over 100,000 GPD:'Copy to DWR,CCPCUA
� Permit Program,1611 MSC,Raleigh,NC 27699-1611 -j'o It.04/
13a.Yield(gpm) /t� Method of test: .�"''rt.6-4P� Gam'`"
70%HTH oZ DATE SITE VISITED: a`(,I Z.Z-
13b.Disinfection type: Amount: 6.6 -
" fl VISITED BY: hie -
Fri CP_I L-__._,n....m.. nr.,:an.,Ave Vllet.rir.eenfr.c Revised 6-6 2018