GW1--04440_Well Construction - GW1_20230710

i1,d it cC�IY�11iT�1LTtl:Tl1t�l�T .C'C ( �ZI-1 For Internal Use Only:
1.Well Contractor Information:
/ -i/Xe hi firo kin 14.WATER ZONES
FROM TO , DESCRIPTION
Well Contractor Name ®rsr ft /r� ft• ,. 1p
3031,4 31y ft. 3!G ftl o�O l
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(if a licable) m
YADKIN WELL COMPANY,INC" FROM To/ D 'rHICI04Ess MATERIAL
ft�� ��� ft in. /
Company Name a.L-a'a.`l.c/6( ;et.),E a° f,5.--, 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:�L.IP .. .7Z `�'- I "7 2.G O( FROM TO /_DIAMETER THICICNESS MATERIAL
List all applicable well construction permits(i.e.[SC,County,Slate,Variance,etc.) + / ft S 11 ft' b IA/ in. 5g9,-Q?, PC' -15
ft. ft. in. \`,
3.Well Use(check well use):
17.
Water Supply Well: F SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS
❑Agricultural OMunicipal/Public� X
in. 7- _
❑Geothermal(Heating/Cooling Supply) E lleesidential Water Supply(single) ft. n. M
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ln-igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ° ft" d® ft AV U 6�•• /d/.
❑Monitoring ❑Recovery ft. ft. l tl
Injection well: ft. ft- /et/is- A-ie/I,,DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) `Z'�
❑Aquifer Storage and Recovery ❑Snlinity Barrier FROM TO MATERIAL EMPLICEMENTMEPHOD J
❑Aquifer Test ❑Stormwater Drainage ft' ft
/ .,,,,/
❑Experimental Technology ❑Subsidence ControlC
❑Geothermal(Closed Loop) ❑Tracer
20 DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(cufor,hardness,soil/rock typo grin sire,eta)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) ® ft. �� So•,e/ r 5 /� g�„
.Completed: /�. P,. 21 yLI- ft /-`U ft- /�ci/di .!6�rr.✓1•!., ra.a✓'
4.Date Well(s) b1 /�3 Well ID# �/7 � _ y �y
5a.Well Location: q°>®r3°` r` Aro ft L 7a ft DTP l4r'eG�CI.,`i 6Xd �-g e4'•C.
y 1,�t Phone # n( �'1I- �� ft. y !�® / { ,
z1�� MN IDS • Paul. a-o f'rr/.s,i I f" I i�0 ft P7AP 6�eali�^�.
J �- e
Facility/Owner Name Facilityi/C applicable) 33U ft 3�A ft r�1/cl. /P,r,k 0m°✓¢=a/-L,
1,5- Wz- '- _f OL". Cleve.,-(4.,..i, 21-013 ft. ft.
Physical Address,City,and Zip ° ft. ft. r•• r"1-',r_ ` . r-1.
LI-v d e 21.REMARKS V o L.t...,r 5.....e Sr
County Parcel Identification No.(PIN) J,,L 1 e 2-02 3 yti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l
(if well field,one lat/longis sufficient) 22.Certification: inicil r''"`"'t P!^=r, " -' ;;r.a .-.C.
;s-, 73 7251 N F5-3' -2y- Z " w7. .4( .____16„.7 ,.
c,�,r/23
0
6.Is(are)the well(s): C ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1°1Nt 1SA NCAC 02C.0100 or ISA 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 this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info "C'
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarlo Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J 11� (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')
10.Static water level below top of casing: 5-024a. For All Wells: Original form to Division of Water Resources (DWR),
(ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: C. (in.) Bit Off: 4° ®®U 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
(Le.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
f Permit Program,1611 MSC,Raleigh,NC 27699-1611 q
13a.Xie]d(gpm) �J Method oldest: � �f�j�t� � ,'n��ia
13b.Disinfection type: 70%HTH Amount: t oz DATE SITE VISITED: 3'z -2.3
Pri r_P_! _ I VISITED BY:
Form GW-1 onmental Quality-Division of Water Resources Revised 6-6-2018