GW1--03939_Well Construction - GW1_20230612

-r Ld It toNS 1 .1ucT1ION RECORD (GW-i) For Internal Use Only:
I.We Contractor Information: Z
�'''"N 14.WATER ZONES ��y
�.��1�L� � e' 3�-�� PROM TO DESCRIPTION t•l
I Well Contractor Name 1 QS ft 1 i O ft. I T/ 4.Yd`�
/�j� ft. it g� " CA
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)ORLINER,if ap licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL rri
+1 ]t 1aIf ft- G,1,3 in. Svfl-Pi Poe_Company Name 8 16.INNER CASING OR TUBING(geothermal closed-loop)
Pi
2.Well Construction Permit#: P gal,L"®3-3 00 p-7 FROM TO DIAMETER THICKNESS MATERIAL --1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
V:. ft in. r n
3.Well Use(check well use): ,.4,• .rr ! l/
17.SCREEN
Water Supply Wel( ,`'-- 1::• t -'"1- -• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural f JM oipal/Public ft ft. i
❑Geothermal(Heating/Cjag Supply)L esidential Water Supply(single) ft, ft. in. . /
❑Industrial/Commercial -,.- -�,,,,t,CC77Z s13enttal Water Supply(shared) 18.GROUT ((((
❑Irrigation 1t��'f•`�~tn�,,C+i�-- ❑Wells>100,000 GPD
�"ti&y FROM TO MATERIAL EMPLACEMENT A/CEhfENTMETHOD&AMOUNT
Non-Water Supply Well: o ft. 3 ft. Be4st4tft 14' ,'.t P/.z '`
❑Monitoring ❑Recovery S it. 3�f ft [ (k�/ p�
Injection Well: '( :r r�.+�J �� 1
ft. ft 9
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL EMPLACEMENTMETHOD
DAquifer Test ❑Stormwater Drainage i
DExperimental Technology ❑Subsidence Control ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
S41440.-as/i1 I?3 c� ft. -7d fc Sc.,/ i l bOS! _ 9 L -
4.Date Well(s)Completed:PsIi i 93 Well ID# Ai. ''- --co �® ft 110 ft t4y irt`./.� i tCk a9ta Ad�C/�
5a.Well Location: Phone # - i6�.p�.m tli�. 110 ft. 1�-f IJ°"°wt,��C (j-t1-411 OA
tea
t /
ty O in (ifapplicable) 1 ErS ft. 1gaf` L..oa.yebeS of-f' i e) G�.,.il W
Facrli / erName Facility ID# licable
ft.
211 (Lail! 3�16 ov i�•- E f k I," ft ft.
Physical Address,City,and Zip
21.REMARKS f
County Parcel Identification No.(PIN) t:; L till reit 1c Pas'/ IT'S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Garb c 'on-
3(6 I kg,, rqs- N g0' tg63- ii ST W HPe `9/ a./ .�
6.Is(are)the well(s): rmanent or ❑Temporary rgn of Certified Well Contractor Date 1"
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with '7
7.Is this a repair to an existing well: ❑Yes or 11Vo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy e."
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: ...E
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of thic page to provide additional well construction info U
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. p(
drilled: 9 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 fT (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 2Q100`) G
10.Static water level below top of casing:
�C) (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" //��rg I.
11.Borehole diameter: (in.) Bit Off: C i V / g 24b.For Injection Wells: Copy to DWR,Underground Injection Control PC) [A
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,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-I611
C� (--10
13a.Yield(gpm) f tl Method of test: A,v
13b.Disinfection type: 70%HTH Amount: g oz DATE SITE VISITED: (0 3-"2.
Pr?cc VISITED BY: l
Form GW-1 , Ina Department of Environmental Quality-Division of Water Resources Revised 6-6-20]8