GW1--03355_Well Construction - GW1_20230516

_L 1,CoNs 1k-1JC A j01q i+lC0 dGV 1-�p For Internal Use Only:
,.,Well Contractor Informntion:
Tft-
ZONES
TODESCRIPTION
Well Contractor Nam ft. � s ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells ORLWER if a iicable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCKNESS MATERIAL
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Company Name //� 16.1NNER CASING OR TUBING eothermal dosed-too
2.Well Construction Permit#: 3 / 6- g � CSCREEK
Dikim1'ER TmcIINEss hUTEI UAL ih
in. l
List all applicable well construction permits(i,n.i7TC,County,State,Yarto ce,etc-) P�� � c�® 0 4���53.Well Use(ebeckwell use):Water Supply Well: IAMETER SLOT SIZE THICKNESS❑Agricultural ❑Municipal/Public in❑Geothermal(Heating/Cooling Supply) ?Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) iB.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAI, EMPLACEMENT METHOD&AMODNT
Non Water Supply Well: it IF IL
❑Monitoring ❑Recovery ft 3;.' ft
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/9RAVEL PACK rf n lirable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM xo MATERIAL, EA�LACEMENTMETHOD
❑Aq ulferTest ❑StonnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hardness,30rork G ain she,ctr.
❑Geothermal(Heating/CoolingReimn) ❑Other(explain under#21 Rem(arks) � ft �,7 gft. der
4.Date Wells}Completed: 5-2' +�� Well ID# r 10--/ 14%ft' 2P'it-
ft ft
5a.Well Location: Phone r®•2 E +�w
Fa ID# ifa licable ft' Y � 2023
Feci7ity/Owner Name �' ( PP �
j1�, ft. ft ,r,r 1 �i
C ft ft. un:�
Physical Address,City,and Zip
2x.REMARTCR
County Parcel Identification No.(PIN) e ®o� 6
u6' e T�°e 4 la
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification: {
6.Is(are)thewell(s): Permanent or ❑Temporary
Si a of Cerddi• Well Contractor Date
By signing thisform,I hereby certify that the wall(s)was(,are)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes orID 15A NCAC 02C.0100 or 15A NCAC D2C.0200 lYell Construction Standards and that❑copy
Tf this is a repair,fill out known welt construction information and explain the nature of the of this record has been prmided to the well owner. E
repair render f21 remarks section or on the back of this form. 23.site diagram or ad ditioIlal W ell 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 in
See Over'in Remas Box).You may also attach additional pages if necessary, I
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: p�Q
For multiple wells list all depths Ifd Brent(ezample-3Q200and2Ql0q Vt Submit this GW-1 within 30 days of well completion per the following:
®' Z4a. For All Welts: 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 r
Tfwater level Is above coring,use"+' C
f Borehole diameter (in.) Bit Off: &v®3® 24b.For Iniection Wells: Copy to DWR,Underground Injection Control (IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return WeIIs:Copy to the
(i.e.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 GAD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: �sp�I"
13b.Disinfection type:
70%HTH Amount: & OZ DATE SITE VISITED: �� ��'7--a 2-
Pry r_P e VISITED BY: V6
Fes.,,,t w=l ina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018