GW1--04019_Well Construction - GW1_20230612

L Cu�I"IS T;1�11J�:TII+�l�L +IC�1Y d Cv1-1� For Internal Use Only:
1,Weii Contractor Information:
14.WATER PONES
Well Contractor Name FROM TO DESCRIPTION
-b ft. 72—
NC Well Contactor Certification Number 15°OUTER CASING for multi-cased wells)ORLINER if a licahI
YADKIN WELL COMPANY,INC. FROM TO DIAMETER N_—=6S MATERIAL
ft ft.
Company Name �( 16.INNER CASING OR TUBING(geothermal dosed-loo p
2.Well Construction Permit#: I 6 FROM To XkMETER MUCIMM' S MATE xrpl,
List all applicable well construction permits(i•e.U1C,County,State,Variance,etc) ft ft
y in.
J
3.Well Use(checkwell use): • ft. in.
l7.�
Water Supply Well: FROM
SCREEN TO DIAMETER SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Mimicips.VPublic ft. ft, in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) —. ft. ft, in.
❑Industrial/Cominercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMK ACEMENTT4ETHOD&AMOUNT
Non-Water Supply Well, ® 1
ft. ft. B1 E:�I��,j �sL �!l'� r.✓1 e/%
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(iia livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTNIE,THOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology []Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necesse
❑Geothermal(Heating/CooIingRetum) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,solyrvekain size,eta
Ff4.DateWells)Completed: 5.l 1S-2 WellID#,4A to 3ft. W Wg `mow:?-Sa.WellLoccation: Phone # Fq3 7- 153o �'a ft 56(t lU$11V Cho) 1 Y WC
Faorlity/OwnerName FacilityID#(lfapplicable) ft• ►�dp� ft by tytlfflt c
ft
Physical Address,City,and Zip F GA°a�av o 6 ft ft. i �. ...k J �....a rs' U
A �� 21.REATARKS _�
i d 2LIZ3
County Parcel Identification No.(Pal)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Int/loagis sufficient) 22.Certification: a 1+
3-6 49 N Zr!
6°Is(are)the well(s):,,Permanent or ❑Temporary Signature of Certifie ell Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructedin accordance with
7.Is this a repair to an existing well: ❑Yes or XNo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 wall Construction,4tandards and that a copy
1f this is a repair,fill out known well construction information and erplain 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:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction bh
construction,only 1 GW-1 is neyded° Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box),You may also attach additional pages if necessary.
drilled: / M.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d��� (ft.)
For multiple wells list all depths tf different(eromple-3(n)20o'and 2©1000 Submit this GW-1 within 30 days of well completion per the fallowing:
10.Static water level below top of casing: LO (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
II.Borehole diameter: � (in.) sit off. 41'°tdt� 24b.For Rn_iection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
(ie.auger,rotary,cable,direct push,etc) county
For Water Supply and Open-Loop Geothermal Return Wells:Copy to the �Q
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
(gP ) 0 5 1 Permit Program,1611 MSC,Raleigh,NC27699-1611
Methodoftest: � r
13a.Xield m r .t "
e.m
70°/ HTH OZ DATE SITE VISITED:
13b.Disinfection type: ° Amount: �•
a.A
VISITED BY:
E__ Form GW-1 brimental Quality-Division of WaterResourdes' Revised 6-6 2018 �