GW1--03341_Well Construction - GW1_20230516

,W CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
I.Well Contractor Inforrnation:
1 , ar Pe 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
106ft. Vi2 10 ft'H S-� A 4 a ft. ft _
NC Well Contractor Certification Number 15.OUTER CASING(forniu]ti-rased wells)OR LINER(if sip livable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TBICECNESS 1 MATERIAL P
ft ft. in.
Company Name ''•
{, 16.INNER CASING OR TUBING(geothermal closed-low)
2.Well Construction Permit#: 312_ tf FROM TO DIAMETER THICIINFSS MAIT27AT,
List ail applicable well construction permits(i,e.UIC,County,State,Variance,etc) 11 fit [' ft /f(�c in. )/-1,( P G/� ,
3.Well Use(checkwell use): ft 1' ft. (9 J m' -�V�l
P
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL -.,
❑Agricultural OMunicipal/Public ft. ft. in. (1
❑Geothermal(Heating/Cooling Supply) [residential Water Supply(single) ft. ft. in.
❑Indusarial/Commercial - (❑Residential Water Supply(shared) 18.GROUT
' ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIPALL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. as ft. ►i.r1 1�+1T5 6 JLo-y
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO 111A't'e.RIAT. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUro&type,grain she,etc.)
❑Geothermal(Healing/Cooling Retain) ❑Other(explain under421 Remarks)
1 44
® ft. le6 ft. St
4.Date Well(s)Completed: /'I`I."�_j Well ID#A4®.^Vg f g ft. S6 j1itie
5a.Well Location: Phone # ?O eyd:O/ a 751? : ft'9 ft. 34 ft. frig' J e91 1-
• Pavaid G1«o y ' 9? ft. 519. Gnf( ,.5 _
Facility/Owner Name FacilityID#(if applicable) ft. ft
i ft. ft re..a t,,r ._a 6d': .,)
I. Physical Address,City,and Zip ft. ft. MAY 1 r 2023
`
t1 5 / e- 21.REMARKSi
County Ai Parcel Ident fication No.(PIN) I nfO;it .Y:-.!n to t•^^:�.n..i-1 Uri;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,ode let/longis sufficient) 22.Certification:
3a 33' 3 ', ®.; ''l 35 1,13Y W
6.Is(are)the well(s): Permanent or ❑Temporary Signa C ed Well Contractor Date
By signing thisform,I hereby cert5 that the well(s)was(were)constructed in accordance with
• 7.Is this a repair to an existing well: ❑Yes or Ago 15ANCAC 02C.010D or ISA NCAC D2C.0200 Well Construction Standards and that a copy
Vas is a repair,fill out?mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this fornt.
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 i 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: 1g.` (ft.)
For multiple wells list all depths ifdii different(example-3©200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 56' (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (rr (in,) Bit Off: .�i 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) It.
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 '
(i.e.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA S
13a.Yield(gpm) I Method of test: i�i Permit Program,1611 MSC,Raleigh,NC 27699-1 bl l $ v
13b.Disinfection type: 7"HTH Amount: ' t OZ DATE SITE VISITED:,`�`Z .°�.! _ s
Pri r_
I ' VISITED BY: Vit3
Form GW-1 iaDepartment of Environmental Quality-Division of Water Resources Revised 6-6-2018