GW1--03422_Well Construction - GW1_20230516

L-`C ONS TREC ION LR1 cO1 ➢ (GW-1) For Internal Use Only: .
1.Well Contractor Information:
3ecr7 jOl4c 1,13 . 14.'WATER ZONES -
FROM TO DESCRIPTION 'CA
Well Contractor Name
ft. j I O fr. 3 (s Ptvi l--
�J" 4 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLINER(if ap limbic)YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS 1 MATERIAL
ft. ft. in. t >
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) �J
2.Well Construction Permit#: 0 5.5a..., FROM TO DIAMETER THICICNESS MATERIAL c'-.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) i/ft 7 q ft G liq in. SD R p( 1�Uc �e
3.Well Use(check well use): ( ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DNlunicipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) kic'sideutial Water Supply(single) • ft. ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL ' EMPLACEMENT METSOD&AMOUNT
Non Water Supply Well: ® ft Li ft. /4 Be Pi v5 Pov-1at9 li 64
OMonitoring ❑Recovery 4 ft ?1.0 ft. dli,Ck 6Dyat 11 3 bass
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediatidn
19.SAND/GRAVEL PACK(if applicable) )
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Rematics) ft'
t �S
4.Date Well(s)Completed: 711/1 2'3 Well ID# (/ 68 Rft. /63fr lirai r r;t.^-_.- :.
5a.WellLocation: Phone #G7 atyf-f ,n.-_fi 1• '.l�..:',..
ft. • ft
•
4'� / o ft. MAY ? 5 2023
Facility/OwnerName Facility ID#(if applicable)
Physical Address,City,and Zip cert&L .ti'J LI ft ft.
i, / ii-es 5 21.REMARKSiV _ r�
County Parcel Identification No.(PIN) Mat S'!� 3 6 e� COr 1 W O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/longis sufficient) 22.Certification:
36 4( ref N f'l a3",Age3? w .6-2
4!/®rle3
6.Is(are)thewell(s): ermanent or DTemporary
Signatnreeoo Certifier)Well Contractor Date
Bysigning this orm,Ihereb cent" that the well(s)was(were)constructed in accordance with
�'g f y dy
7.Is this a repair to an existing well: ❑Yes or pRo 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 itlfarmalion and explain the nature of the of this record has been provided to the well owner.
repair under 2l retricekr section oron the back ofthisform.
23.Site diagram or additional well details:
S.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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction;only 1 GW%is needed. Indicate TOTAL NUMBER of wells
drilled: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth bow land surface: 11-16
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3© and and Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 600 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
. 11.Borehole diameter: 6 (in.) Bit Off: 6.060 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
n '
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yl0.id(gpm) Method of test: 4d
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH 3 OZ DATE SITE VISITED: " a
13b.a.Pl+,inYeetioD type: Amount:____ �-
Lorirrt' •
�_ VISITED BY: � �
Rnrm c W-� Ironmental Quality-Division of Water Resources Revised 6-6-2018