GW1--03352_Well Construction - GW1_20230516

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w''AL CoigS 11R1CTC1T1 ON-?1,E CORD (,Cw-1 p For Internal Use Only:
1.Well Contractor Information:
���� �1`•� 14.WATER ZONES
FROM TO DIZSCRIP17ON
Well ContractorN e
•� ® ft' /1 ft. SdA r4i1W J-,
NC Well Contractor CedificationNumber 15.OUTER CASING for multi-rased WeIIs ORLINFR if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCLQ4ESs MATERL4L
ft, ft. in.
Company Name
16.ROM CASING OR TUBING( eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAME= THICHXrSS MATERIAL
List all applicable mull construction permits(ie.IIIC,County,State,Yarionce,eta) 9ft •J 9 it ®� - �a A t>�1�•�
3.Well Use(check well use): a M ft. in. t
Water Supply well: I1i0117. iREErTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft, in.
❑Geothermal(Heating/Cooling Supply) IL9Residential Water Supply(single) • ft. ft. in.
❑Iudustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 3 .- ft. ®w-L
❑Monitoring ❑Recovery 3 it T ft. �!
Injection Well: �JIOYOM
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.
rSto and ❑S Barrier FROM
PACK Ifa linable)
❑Agll1fE rage Recovery abmty FROB4 TO MATERIAL ... EMPL.ACEMENTMETHOD
[]Aquifer Test ❑Stormwater Drainage ft it.
❑Experimental Technology .r ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) _.111Tracer 20.DRILL7TTG LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) . ❑Other(explain under#21 Rema>ics) FROM To Dx.scRZP11oN �mr,nanlnrss,anmracx a .na 5 u eta
4.Date Well(s)Completed. ��. -3 WeuID# 77Y 7 Jy-ft
5a.well Location: P}lOf1B # 4 D ®q8�s•9 •� ��� �s�►%s�,• �;' r;l
ft ft
Ape �A
Facilify%vr Nrime li Facility ID#(if applicable) ft ft �. L G J
fr. ft �racs=ni,q LJri
Physical Address,City,and Zip ft It.
21.REMARKS
County Parcel Identification No.(PIN)
46
5b.Latitude and longitude in degrees/minutes/seconds-or decimal degrees: s �'
(ifwell field,one latilongis sufficient) 22.Certification:
443
6.Is(are)thewell(s): ermanent or ❑Temporary Sign ofCertifie ell Contractor Date
qq��,,,,,,,,�- By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and thal a ropy
If this is a repair,fill out known well construction information dn2texplain the nature of the ofihis record has been provided to the well owner
repair under 921 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 i GW--1 is nleded. Indicate TOTAL NUMBBR of wells (add See Over'in Remadm Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 49'�® s (ft.)
For multiple wells list all depths 1fdifferent(example-3Q200'and2@100) Submit this GW-1 within 30 days of well completion per the following:
C.
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
Ifwaier level is above casing,use"+"
Il.Borehole diameter (in.) Bit Off' �° rib24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27 699-1 63 6
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc) county environmental health deparhnent of the county where installed
FOR WATER SUPPLY WELLS ONLY:. 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
IF Permit Program, MSC,Raleigh,NC 27699-1611
23a.Xield(gpm) 36 Method of test:
13b.Disinfection type: 70%HTH Amount: �. �� OZ DATE SITE VISITED:Z40-(,,
Pr7i1 - --�- VISITED BY: -._ b/A W__