GW1--03921_Well Construction - GW1_20230612

b
(G W- ,
a �L CONSTRUCTION ILL,C1Q 1 e For Internal Use Only:
-
1.Well Contractor
Contractor Information:
6 #M ) .(0 Loin 14.WATER ZONES
Well Conh`ac�torName FROM TO DESCRIPTION�!d 73,5-ft. ` 3 ft.
ft. it. _
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if appQlicable) �
YADKIN WELL COMPANY,INC. FROMx TO DIAMETER THICKNESS NIATERIAL� 6
Company Name 16.INIVER.CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 343 0 J! FROM TO , DIAMETER TEl MATERIAL '�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) -Fl ft. q9 ft. / Il in. s ez-.2 I _ ®v/"
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICICNESS MATERIAL, 11111 ,
❑Agricultural OMunicipal/Public ft. ft. is
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. t. in, .,
❑lndustrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT t
Non-Water Supply Well: 0 ft. ft. ift� 1 4- al _t, Gam.,' 17 /3 CA
DMonitoring ❑Recovery ft. ft. �'
Injection Well: r-
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) _ ("''''
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMLTHOD
❑Aquifer Test ❑Stormwater Drainage f
❑Experimental Technology ❑Subsidence Control ✓ft /
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheet if necessary)
DGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,aoiltrocictype groin sae etc.)
� ) ft. 2rft. t
4.Date Well(s)Completed:le �6/1/at 3 Well n)// '/i 7 � .(.,r ft- 92 ft• 1.4.4c ,( sDe17,/ 4„4.,
5a.Well Location: J/`�AI Phone # 3 0 /2-? l5z:. qa- ft. s®"�- ft. K�iCioP)
/- r dt I 1 ,rut ft. ft �1 .J .el� 4�
11Z Cltth 2! Cf^ �/8r I � tIYG `a(�e�/ ft. ft. t 4,,... r -
Facility/Owner Name Facility ID (if applicable)
�.E'� !a6 l btJ4,t'er. Vitro ft ft. J�iv 2 2Q23
Physical Address,City,and Zip, g26s\ '. ft ft.
1
Wei / g/ 21.REMARKS t1:,:T`"r,A r-cw,-Nr2-LL.I r'^
ek 11
County Parcel Identification No.(EON) qv 6 / d/4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
36 I3, earq N 11 Q3,$ga.15- W 6 ,. i -.23
6.Is(are)the welI(s): Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orYo ISANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of ihisform.
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 fdeeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f7 0 /For multiple wells list all depths if different(example-3(E1200'and 2Q1000 (ft,) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 'V 0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Bit Off: 6 a 0 7 24b.For Injection Wells: to DWR,Underground Control(IUC)
Borehole diameter: � (in.) Copy � Injection (N )
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-LoopGeothermal Return Wells:Copy
(i.e.auger,rotary,cable,duectpush,etc.) county environmental health departmentf the county where installed to the z
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
f Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)" - ' Method.of test: . Cie y
70%HTH. OZ DATE SITE VISITED: I e 5.2, cs tri
13b.Disinfection type: Amount:
• . riattlyi' < sir •2.ePsn,4",sealoes ca,-. , x- ._:awtti. VISITED BY: L/,g 4.
Form OW-1 onmental Quality-Division of Water Resources Revised 6-6-2018