GW1--03940_Well Construction - GW1_20230612

' "'t�FE 1,CONSTRIUCTI.ON RECORD(GGW-1) For Internal Use Only:
1.Well Contractor Information:
Fri dlt-eae%'---3-e,r-i: t iota- 19.WATER ZONES (
FROM TO DESCRIPTION �1
Well Contractorntp Name j'S ft. �� ft. �%�
IS
V'��r 77 is ft. ft ,,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable) Z
YADKJN WELL COMPANY,INC. . FROM TO I DIAMETER THICKNESS MATERIAL
ft. ft Ir in. �V)
11
Company Name q �1 �{ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#e/A��, eC 0.12 0 JO / FROM TO -DIAMETER THICIINESS MATERIAL
List all applicable well construction penni s(I,e.UIC,County,Slate,Variance,eta) 4./ f ff 1 ft 6.1 a6 in. .S, ;-9 Q pLi L Z
3.Well Use(check well use): ft ft m I.-
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) C esidential Water Supply(single) • ft. ft. in.
[Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENTEIETHOD&AMOUNT
NNo Water Supply Well: O ft. g6 f- 66mt,4(A, J'-/yri 4 b a� jA®doe1
[Monitoring DRecovery it ft.
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
['Aquifer Storage and Recovery OS alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
,❑Aquifer Test ❑Stormwatcr Drainage ft. ft.
[Experimental Technology ['Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG.(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sop reek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
4.Date Well(s)Completed:ot&IIYAY1 3 Well Wit MP-IV '-)0 ft. 1. 7 ft. d *+t'4.1 ���y'9 icof
5a.Well Location: Phone # o 1-4(co-G3� g7 fr. /®9- ft' 6 ,'kf �y,-...),, I,li[-c
• ���� �blt��s A. `ram�l -_ 0 , - ft. t Lie,ft I-4Ys v-y j 6- ,r'A.i f -y l 6/ 4-e j�
Facility/OwnerName Facility ID#(if applicable) ft. ft.
t ; so 4--••;4 p••••
ft. ft ► t ..�.i i �3 i
Physical Address,City,anG Zip ft ft I(j IN I 2 2023
21.REM.ARIGS ,
S LA In(rY In(+,u�l^.sz:in ?t in: Lr:.l
County / Parcel Identification No.(PIN) `t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: oS
(if well field,one 1at/longis sufficient) 22.Certifi ation: 4
6,.... 4/ Z.,... ....,...... .._... t2C/A149e-)969
6.Is(are)the well(s):permanent or ❑Temporary gn e of Certified Well Contractor Date
/ By signing thisform,I hereby certy,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: :Yes or ATo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy ICI
If this is a repair,fill out)mown well construction information 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. V
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loo 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 peeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remy Box).You may also attach additional pages if necessary.
drilled: C [,/ 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: /L (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3Q200'and2Q100')
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
Ifwater level is above casing,use"+"
11.Borehole diameter: 6 (in.) Bit Off: 6, 0.5 9 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Progranl,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: a 0v P
70%HTH , OZ DATE SITE VISITED: , `2 -1.Z-
13b.Disinfection type: Amount:
VISITED BY:_ i✓,6
1 pForm GIN-1 ental Quality-Division of Water Resources Revised 6-6-2018