GW1--03426_Well Construction - GW1_20230516

CONSTRUCTIONiIC� For Internal Use Only:
A.Well Contractor".Jor,Jntion:
l7(B' 14.WATER ZONES
Well Co aLis FR01M TO DESCRIPTION
Lo5 ft. ft.
NC Well Contractor CertificationNnmber I5.OUMR CASING for multi-cased webs ORLINER tf a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL.
ft, ft in.
Company Name 16.ETM CASING OR TUBING( eothermzl closed-loop)
a DIANII I'ER TMCIINESSMATERIAL p t
2.Well ConshuctionPermit#: 33� / 6� FROM TO
List all applicable well construction permits(ae.VIC,County,State,Variance,etc) 1 ft 1-5i ft in to
3.Well Use(ebeckwell use): ft
Water Supply Well: 17.SCREEN
FROAL TO DIAMETER SLOT 5I2;E I THICIC1YE55 I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) [residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial (❑Residential Water Supply(shared) 18.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM I TO MATMUAL EMPLACEMENTTkWTHOD&AMOUNT
Noa--Water Supply Well: 2 ft' 3 �ti,,(AA6 41 e,%V ' ®�J
❑Monitoring ORecovery it ft.
Injection Well: ft, %
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf a livable) i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTR=, OD
❑Aquifer Test ❑Storinwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRMLINGLOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolmgRet ua) ❑Other(explain under#21 Remarks) FROM ft TO ft. DESCR=ON color,hmrdness,sail/mck r-gnau sae,etc
4.Date Well(S)Completed: WeII ID# !� _� ft' 90 WCOA P`6 C
5a.Well Location: Phone # Fula-1i3-to7S6ft- C-3°�
Prof 91P-� �5
Fao:lity/OwnerName �� Facility ID#(if applicable)
/A ft. ft
TmA T Jay] C4rf� ,6 -,z
�— o® ems. ft ft 7
Physical Address,City,mad Zap / o eo
"Yg h..g A,--, MAY
REMARKS AY
cc ty Parcel Identifi ration.No.CMD 207
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - ' -
(ifwell field,one Wongis sufficient) 22.Certification: Cius}C"Ua•--; . _—____ _..._ _
,3 G IS N K/ 3 7 re 63 W
6.Is(are)thewell(s):PPermanent or ❑Temporary
S' ata a of C e ell Contractor Date
;By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an eldstingwell• ❑Yes or *No ISANCAC 02C.O100 or l5ANCAC 02C.0200 WEII Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplaln the nature of the of ihts record has been provided to the well owner.
repair under 421 remark section or on the back of this form.
23.Site diagram or additionalwell 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 Remarla Box).You may also attach additional pages if necessary.
drilled: i 24.SUBMrrrAL 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 ifdifferent(erample-3@200'and2©700D
24a. For All Wells- Original form to Division of Water Resources (DWR),
Jf Static water level below top of casing: ® (ft.) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
If woier level is above casing,use"+" �°
/ Bit Off: 74b,For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: [2 (in.) Program,1636MSC,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 over 100,000 GPD: Copy to DWR,CCPCUA
c Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of test: d�/�
y 13b.Disinfection type: 70%HTH Amount: 119 Oz DATE SITE VISITED: f Z
VISITED BY:
-Pr!et-��
r1 rimmural Otwifv-nivicinn of W.f-.rR-e n—, R-vic-d 6-6-oniR