GW1--03344_Well Construction - GW1_20230516

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, "a ":Ll,CONST.1 'NCTIItON l CO)R t(GI/V-1 p For Internal Use Only:
1.Well Contractor Information:
I ' 1 '` 1 011
£ Cave 14.WATER ZONES
Well Contractor ac(yName FROM TO - DESCRIPTION
J l 7-/}- '�l6 t. O fr. 50 c1'"" 50Ai
NC Well Contractor Certification Number 5-5-6 ft ? it
15.OUTER CASING(for multi-rased well4 ORLINER(if a limbic)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER , THICKNESS MATERIAL
ft. ft. in.
Company Name 7 // 26.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 W FROM TO DIAMETER T13TCKNESS MATERIAL
List all applicable well construction permits(i a UIC,County,State,Variance etc) .�.1 ft. rr t ft '0 i 1?0 c... , , e c
3.Well Use(check well use): ft. ft. in. P
....1.
Water Su 1 Well: 17.SCREEN _
Supply FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public it. - Cr
.5
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) . ft. in. "_�
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD de AMOUNT '
Non-Water Supply Well: O ft. ft. 0(,1 /�`ryj�e 1..�o� i p.1vo �,6.i k'i
❑Monitoring ❑Recovery it a Lf ft. eivyk 4;i-e c1(Arrx I` li-cm/it"
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVES.PACK(if applicable) -�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEIVIIiNTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft
,1
❑Experimental Technology ❑Subsidence Control ft. rif
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) F
FROM TO DESCRIPTION(color,hardness.soil/rockty pai
n ain sae,etc.)
❑Geothermal(Ileating/CoolingRetum) ❑Other(explain under//21 Remarks)
9 Li')3 L d ft l2 ft Sde•,
4.Date Well(s)Completed:_1_6'.- a3 Well ID#/*�P-/ 7 S '(2. t. /? ft. /4,7 9 /+m/1
5a.Well Location: I•zri..I' Phone # 33G4y1I4C 5.- ►' ft a3Sft"
0;"1r;d5 47.. 5/744j1 '"'"1/ .44)
• /4lle� 7��ldv� R3�..g77-4 r33 oZ7S ft 7 it tviir ✓ -fur"' 5✓:, v 3sx•1.tt
Facility/OwnerName PacililyID#(if applicable) 3 7s ft. 3 9S ft' i
1'fv roe, (\ 1.
q`1 wA It R`�`c/ Laws/Ap 3ci s ft- rox ". ftwn rA-e �''-� ,5 "/".
ft ft.
Physical Address,City,and Zip �7 C.,a�43 �= 4.o�-." ', : �4l--.
I r - s 21.REMAIUCS
I
County Parcel Identification No.(PIN) MAY 1 2Q23
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: to{�,,;,: r; .'r:-.'-•!.---•'--3 t Ir
j (ifwell field,one let/longis sufficient) 22.Certification: G;+1 :3O'=
3 3114_,e 17(7-51 N 5-1 3 7. 65,s'3 W
0/ • C-Vt. Li-6-023
6.Is(are)the well(s):,errnanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby cart(t that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or /efNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
b.-this is a repair,fil!out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair wider#21 remarks section or on the back 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 Remarim Box).You may also attach additional pages if necessary.
drilled: C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ®2, (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4)200'and 2Q100')
° 7Aa. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+" /
(o (in.) Bit Off: 6 I D/
O 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636 1
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
R`ft F¢R WATER SUPPLY WET.T 4 ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
t / Permit Program,1611 MSC,Raleigh,NC 27699-1611
T 1 13a.Yield(gpm) � Method of test: �s�`" 4
13b.Disinfection type: 70%HTH Amount: Al- Oz DATE SITE VISITED: Y(^9=24 U
ti
l 't1v VISITED BY: ge
Uri r�P' -
"'Form GW-I rota]Quality-Division of Water Resources Revised 6-6-2018