GW1--03353_Well Construction - GW1_20230516

WFI,L CONSTRUCTION RECORD For Internal Use Only: TTI
1.Well.Contractor Information:
t�.14 WATElf7ANIaS`ile4iz;:',2:: :' T
i
Well Contractor Name FROM TO DESCRIPTION
ft. ft
ft. ft y'
NC Well Contractor Certification Number 15.QU=C}1SR'IG foi multi c®sed:tiveIIs':ORLIlVET2'i#s licalile' ",.
Yadkin Well Company, Inc. FROM To DIAMETER THICIaQFss MATF,RTAT x
ry fr. ft im �1
Company Name6, JJ � %b- �`� �'�
�9' d a �eq a16Il R:GASII�GOft1QBING 'c'otffietmnl`d6ted=IS'o = -
2.Well Construction Permit#: 1 l l li nq FROM TO D THICKNESS �•MATERiALT
List all applicable well construction permits(i.e.UDC,County,State,Variance,etc.) .�,d ft. B®� ft in. ' _/�. z
3.Well Use(check well use): ft, ft in. / �?e
Water Supply Well: a:]_7::SCREF�'-•=1���--��v"_��=_''�1:_-_-��_�.�'�.�_<<`=�A.'e. :.';;a:�:
FROM TO I)MMETR.A SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/PubIic ft ft in.
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation []Wells>100,000 GPD FROM I To MATRPJAL E117PLACI MLnr MEMOD&AMOUNT b\'
Non-Water Supply Well: ® ft V' ft 0 W
❑Monitoring ❑Recovery ft Xyit
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
❑A er Storage and []Salinity Barrier FROM S/1NDlGRAVELYACIC MATERIAL
q� Recovery tY PROM TO MATERIAL EMPLACEMEtVTMETHOD__a
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
Geothermal(Closed Loop) ❑Tracer L20:DI2 �NGI b'G"tlttach idditioaal`sheeti 'c`r3s_ "__
❑
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCRD TION(color,Lardaess,aoillrrock a size etc
Date Well Started 4Q ". C/& ft. d
4.Date Well(s)Completed: —a 3 Well ID# _ 6 fr. e
5a.Well Location: Phone#-3 0'acla:1 ft ft
ft. ft
Facility//Owner Name p Facility ID#�(iiifapplicable) ft• ft.
8�a ��.�.ye 1, @6:5��� Q°�� ��G�- rtb"sQ.0 ft. ft T t A,+ � ,..:..✓ .p
ft. ft MAY' S' 2023 _
Physical Address,City,and Zip
e„t r✓9,6.. Yin Gr7'h• "ril t�C'`�' '
County J f Parcel Identification No.(PIN) 'r" kd gf Cd
y.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e�
(if well field,one laUlong is sufficient) 22.Certification:
6,Is(are)the we]I(s): 9dermanent or ❑Temporary
SiEP&of CertPd Well Coffitract6r Date '
,� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair'to an existing well: ❑Yes or n4 ISA NCAC 01C.0100 ot•1SANCAC 02C.0200 Nell Construction Standards and dart a copy
If N$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.
K
repair under#21 remar7z section or on the back ofthis 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 ne ded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. �.
drilled
® 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)For m Submit this GW-1 within 30 days of well completion per the following:
multiple wells'&&all depths if different(example-3Q20 'mu12 a@100�
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water'_Rgsources (DWR),
If water level is above casing,use
Infomration Processing Unit,1617 MSC,Raleigh,NC 27699=16'17 ,
"+" �
Il.Borehole diameter _ _(in.)Bit Off: ®�3� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: Y ��� 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 a
FOR WATER SUPPLY WELLS OJsVLY: 24d.For Water Wells producing over 100, 611
000 GPD: Copy to DWR,CCPCUA Q
s i(j®" t�j 699-1
013a.Yield(gpm) ethod of test: Permit Program,1611 MSC,Raleigh,NC 27
�®
70% hth Date Site Visited:
13b.Disinfection type: Amount: l �• oz Site Visited By: d a
Form GV'-' *T^ah r-•^ ^•r�e�+ P^�^t W—imumental Quality-Div'sion of Wa r Resources Revised 6-6-2018
Price:.