GW1--04016_Well Construction - GW1_20230612

vyl';L,,,CC,)NS RITJCTI'�N 1 ' CORD�GW-1) For Internal Use Only:
�71 del!l_ontractor Hntbrron"Hon:
t V, 14.WATER ZONES
Well Contractor Name" FRO112 TO pPSCRIPTION
ft, S ft. ,fib GPn^ (7"
_ C �{3'� ISO ft. S5 ft NO Grp+'► KI
NC gell Contractor Certification Number
IS.OUTER CASING formulfi-r�sed�wells)ORLTNER rfa Licahle
YADKIN WELL COMPANY,INC. FROM To DIAMITER TffiCxivEsS MATERIAL
Company Name 16.I NERCASINGORTUBING eothermalrlosed-loo ) e
2.Well Construction Permit#: FROM To DIAernMR THIC04ESS MATUZI L
LW all applicable well constructionpei nfis rLa.111C,County,State,Variance,etc.) ft 7.3 ft in. SO v2 J Pve
3.Well Use(checkwell use): ft. ft.
Water Supply Well: 17.SCREEN
TROM TO DIAMETER SLOT SIZE TIECIOU.SS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) �tesidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1s.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACENIENTMETHOD&AMOUNT
Non-Water Supply Well: ® ft. ft. I40(e Pl P ur�4) &I
❑Monitoring ❑Recovery L4 ft a(0 ft. Ouutc &O A
Injection Well: S
ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I EMPLACEMENTD=, OD
❑Aquifer Test _ ❑StormwaterDrainage ft R
❑Experimental Technology ❑Subsidence Control ft ft
OGeothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheetsifnecessary
❑Geothermal(Heating/CooliagBettun) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,bardnas,soillmck .'n sae,etr
0 ft' ft. Soil
4.Date Wells)Completed: S I��I�3 Well ID# P— t/-R 0 30 ft ft
5a.Welll,gcation: Phone #�0 -��-c���CD$ ft ft.
fL
ft
Facility/OwnerName Facility ID#(ifapplicable) ft. ft `-" --- —i' t--
/�, ///�ht.� .��s �c�.® 1J�s ft. ft. JUti ? 2Q23
Physical Ad rr�ss dity,and Zip s Lfo ft ft
S/L C i 21.REAIARTCF
County Pmoel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
2_5 /i S-tr N /� az, �W Q
6.Is(are)the weli(s):-Permanent or ❑Temporary Signaturl of Cerlifird Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or*0 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction,4tandards and that a copy
If this is a repair,fill out 7mawn well construction information d 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 thisform.
23.Site diagram or additionalwell details:
S.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 need�d. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:, pp 24.SUBAff TAL DZSTRUCTIONS
9.Total well depth below land surface: ®e�, (ft-) Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths Jf dierent(example-3 c 200'and 2@100�
.30 ft 2sta. For All Wells: Original form to Division of Water Resources (DWR),
if c Static water Ie a below top of easing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
11.Borehole diameter: (in.) Bit off-• 6.O 31 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636MSC,Raleigb,NC 27699-1636 '
AIR ROTARY
12.WeII construction method: 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 ofthe county where installed 4
I {
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 10 Method of test: s
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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M�
13b.Disinfection type: 7D%HTH Amount: —7 OZ DATE SITE VISITED: 6
_ ...--- --- -- — — — VISITED BY:
Form OW-1
nmental Quality-Division of Water Resources Revised 6-6 2018