GW1--03965_Well Construction - GW1_20230612

W'nL CONS 1T RUC 111T'ON RECORD(OW- ) For Internal Use Only:
1.Well Contractor information:
/el slC 4 -.i-/ ,✓<,.J IS t 4i/'61 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION q
.7®�c7 �i .1 ix- ft. ,,f ft.�, 'Jr-' 3� 3B�'- ®L y4.
NC Well Contractor Certification Number 7J'R 2 S it.
15.OUTFR CASTING(for multi-1'dsed wells)OR LINER(if a livable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
�ft ..
Company Name al'�J:_`":9 ml a(+1 704,66 if- 37o.�
16.INNER CASIING OR TUBIN (geothermal closed-loop)
2.Well Construction Permit#: I i crna C1 J lF 2 FROM TO G
DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.VIC,County,State,Variance,eta) 4 / ft. 6 O ft• r' l=, in. e�, /n`ate Pvt. �,.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN �q
_FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In..,
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. /n. . ! //
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 8 ft- Q� /^>� �. 5.6 6(' .,.'j, 1 Y'
�u( Tm J _ ,J 41.
❑Monitoring ❑Recovery ft. ft. ()
Injection Well: ft. ft. &r wAi f•�
[Aquifer Recharge ❑Groundwater Remediation �� j4�,f .
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Test ❑Stormwater Drainage ft.
❑ ..„.Zft Experimental Technology ❑Subsidence Control ft.
'' ❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ,
OGeothermal(Heating/CoolingReturn) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,eoiUrocktype Brain sae,etc.)
I
4.Date Well(s)Completed: rt �D �3 Well TD# .� ‘6)� ft 7, ft. H�� art„�i � itt
P i(i bpi %e. t,-I ft. ft.
fi 5a.Well Location: Phone#zu-,6os 1'.Ctq +
�heb1 cdt Z¢iy"✓cla0CliC .a¢�i! In`_..r°.__. '��. .0 i P
d Facility/Owner Name Facility ID#(if applicable) ft. ft. L ti� �.� i V SA.�+
fit+
. IV(� (� 7ILN c �P,r'l(� tag. Atkin ft ft. J�iti 1 3 2023
ti Physical Address,City and Zip ft. ft. i°d'
���1 IPP • r.rvw � .-�.. I,'
��'l 21.REMARKS ^ C.: ",•...v +
County Parcel Identification No.(PIN) ,
(/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l
(if well field,one lat/lgng 5sufficient) S-C• 22.Certification:
'35', '75 ; ' N /0, g'D w __‘ ---6L6,---, %/.20/a3
6.Is(are)the well(s): El ermanent or OTemporary
Signature of Certified Well Contactor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes oro ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
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 thisfarm.
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 isgeeded. 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: 3 2 2 (ft.)
For multiple wells list all depths if-different(example-3Q200'and 2Q100) Submit this GW 1 within 30 days of well completion per the following:
c.�0 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
If water level is above casing,use"+"
Bit Off: �t t 8 Z 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636 Z
AIR ROTARY
12.Well construction method: - 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the c
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed R
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA ,,C
I, Permit Program,1611 MSC,Raleigh,NC 27699-1611 ,�p
13a.Yield(gpm) 3O Method of test: r t -� VI P
70%HTH 3 OZ DATE SITE VISITED: 3 - �u2'i
13b.Disinfection type: Amount: in
_ VISITED BY: b'�'l -
�T'��Form GW-1 mmental Quality-Division of Water Resources Revised 6-6-2018