GW1--03424_Well Construction - GW1_20230516

RECORD (GW-1) For Internal Use Only:
1.Well Contl•actor Information:
�I
LAA y 14.WATER ZONES
FROM TO I DESCRIPTION
Well Cohtraotorjj-Name 7b ft 71 ft. (�?
NC Well Contractor Certification Number 15.OUTER CASING"for multi-rased wells ORLINER if a lirable i
YADKIN WELL COMPANY,INC. FROM TO DIAMr:TER TEaamss MATERIAL
ft. ft. in. _
Company Name [16.INNER CASING OR TUBING eothermal dosed-loo L
2.Well Construction FROM TO DIAMSI'ER THICI091tss ]MATERIAL 1
List ell oppllcable well construction permits( County,State,Variance etc) ' ft ft in. 1141 c
3.Well Use(check well use): ft. ft. in.
1 r
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural QMt}nicipal/Public ft. ft.
❑Geothermal(Heating/Cooling Coolin Supply) esidential Water Supply r
(H gl g PP Y) PP Y ft. it. in. :e
❑Industrial/Commercial QResidential Water Supply(shared) 18.GROUT C
❑Irrigation ❑Wells>I00,000 GPD FROM TO MATRruAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it 3 ft. 71 do P6 Gov,j '� A265
OMonitoring ❑Recovery ft ft.
Injection Well: ft., f-
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVES.PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft ft.
QExperimental Technology ❑Subsidence Control ft ft.
❑Geothemlal(Closed Loop) 61;' ❑Tracer 20.DILMLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#121 Remarks) FROM TO DFSCRIPIION cuior,hardnes:,soiVroek a ,;n:�,etc
L © ft' g ft 1
4.lpate.Well(s)Completed: Well ID# t IM ft' 1� 5df
5a.Well Location: Phone fL
� C _
� ft ft.f 11 vP /NIC�ISite,
Famay/Own amerN a f Facility IDll(if Uplicable) ft. ft5--
�� �pL� ft. it MAY1 2023 L
Ph sicalAddres ,and r_ ��• :�,•-, ..
i S 21.REMARKS
4
County Parcel Identification No.(PI17) J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) L� 22.Certification:
6.Is(are)the well(s): 2'1'ermanent or QTemporary Signature of C ell Contractor Date
By signing thisfornr,I hereby certl y that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 91 o I SANCAC 02C.0100 or 1 A NCAC 02C.0200 Well Construction SYandards and that a copy
If this is a repair,fill out known well construction info rmai!on and explain the nature of the of this record has been provided to the well owner.
repair under 1W remarks section or on the bock 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-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlm Box).You may also attach additional pages if necessary.
drilled:, 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100D
ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
if- Static water taut:]below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if-water level is above caring use"+"
11.Borehole diameter: (in,) Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(ILIC)
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
(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 aver 100,000 GPD:Copy to DWR,CCPCUA
.� Permit Program,1611 MSC,Raleigh,NC 27699-1611 ��
13a.Yield(gpm) Method oftest: y Ytlh
13b.pisinfeetion type: 70%HTH Amount:, p ep OZ DATE SITE VISITED:
! ; VISITED BY: . �
Pri c��"
V.—[TW-1 Ital Quality=Division�of WatecResotuces Revised 6-6-2D18 /1