GW1--03346_Well Construction - GW1_20230516

• N C NSTR'UtC T11[ON RECORD (MST-l) For Internal Use Only:
D
1.Weil Contractor Inebrmntion:
Ilk�►t J e S0C) y CV2)14.d'( ,dWlA@ I W• 14.WATER PONES
Well Contractor Name PROM TO DESCRIPTION r)
as �g q ,}[ ` �y / gam_
_5 d_'- /e j^p i..t [k0.�et.t�- 3DJ 4' '`I 5 f t 1 50 fr L 19 ® e Y'
ft. ft.
NC Well Contractor Certification Number (Cmo 'f"i- 141,.(,) 15.OUTER CASING(for Multi-cased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: `L FROM TO DIAMETER THICKNESS MATERIAL 4:..
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,eta) it-,l n 94 ft. 6..5 in. I 1 fcS ail 'ke J
3.Well Use(check well use): ft. ft. in. 9 d
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
1
❑Industrial/Commercial . ❑Residential Water Supply(shared) f�
16.GROUT ray
❑Irrigation ❑Wells>I00,000 GPD FROM »-79, �{
�p MATERIAL EMP CEtMIENTMETHOD AMOUNT
Non-Water Supply Well: 0 ft. 7 ft' 1'ft-4Vni['G 6 i '1 1\1f&f.-$
OMonitoring ❑Recovery ?? ft 21 fce ft. /�_h f tl 11.cYfli f InyntrA
Injection Well: {!� `[ a
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 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)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUroektppq grain size,etc.)
ft V ( ft c
4.Date Well(s)Completed:0/ fir 91 Well ID# )O"9 IC V ,gr/ ft' igr, ft" pi 41�fried? (j T =
ft. ft.
5a.Well Location: Phone kE 77} /'m ' ' i° •-,7-)
ft f v.a,--' ,r b. a °i ? 1.✓
PA...v Ii S'm rile ' /ie/�4/7-4 a*/
Facility/OwnerName Facility ID#(if applicable) ft. ft. MAY 1 5 2023
A .tt.Q j✓1at4hrls,9'is. ICaQ ri ft. lnf::,n-J,'2n Pr:. 177M3 L'r:
Physical Address,City,and Zip ft ft �C.'a't0.f'3',7.1 ':
_ 21.REMARKS
iit'c
County Parcel Identification No.(PIN) 6)5 Mt/b,•p 1r 0
5b.Latitude end longitude in degrees/minutes/seconds or decimal degrees: Ild Se f
(if well field,one lat/long is sufficient) pp�� ?//[� 22.Certification:
rr
J4 ' Z-.---
6.Is(are)the well(s): ermanent or ❑Temporary ign of Certified ll oohacror Date
By signing this fonn,I hereby certy5ithat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ,To 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 information and explain the nature of the of this record has been provided to the well owner.
repair under#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 i§needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: Ji.,
),p� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ISO (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 1QI00)
24a. 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"+"11.Borehole diameter: (.� (in.) Bit Off: C n b�
/ 0 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
(ie.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,CCPCIJA
g Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) II Method of test: 113
13b.Disinfection type: 7Dn/a HTH Amount: OZ DATE SITE VISITED: IC�:Z 2 c' ..I
VISITED BY: 16 d��ai L
Prir_P1 -
FormGW-1 onmental Quality-Division of Water Resources Revised 6-6 201E