GW1--05120_Well Construction - GW1_20230818

-i 1 ,CONSTRUCTION R GORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
4 y 'Potts14.WATER ZONES 1 ' ,
Well Con ctorN me FROM TO J DESCRIPTION
C 1 35 ft. t3 i, ftd® iR!`� t i IfC•-, ft'•o c' v. f. •.�
�q� ���( ft. 1 ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(if op livable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
2.Well Construction Permit#:
7 7 J 16.INNER CASING OR TUBING(geothermal closed-loop)
/y FROM J Tn DIAMETER THICKNESS MATERIAL h '
List all applicable well construction perm s(i.e.UIC,County,Slate,Variance,etc.) it � 't• 6� in. I� � � ►1
3.Well Use(check well use): ft. ft. in. O. 1 3"
(r
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial Residential Water Supply(shared) 18.GROUT
DInigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT q
Non Water Su!DPP �1 t.A 7 e `J E Q V ft .N;'li- ft. i a v�'° CiaS 10-y
OMonitoring Recovery ft. ft. 3-,
Injection Well: AUu 1 8 2023
ft. ft. Po Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Sto tan ,S9PY-AYCtwl+s+9 U alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD v
DAquifer Test emoitoe ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. it
❑Geothermal(Closed Loop) ❑Tracer 20.D1ULLING LOG(attach additional sheets fnocssaa ') CP
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrork type,grain size,etc.)
I) it. ft 5-0;1
4.Date Weli(s)Complet-_ 7'1G' _Well tD# P g ft' 75 ft. C> vi l-C
R
5a.Well Location: Phone # ` 0#4-60q'RZ5a, s ft ftsark8• `Cj- t'
b-vadieyPotic-e. F7.5/-oob- Lkoln . go ft. Va® ft CI Ninaft. ( $ i
Facility/Owner Node Faclity MA(if applicable) 1'a l ft. 6 3 ft. Srekri
1 hardIQ
� t ei( o
4n� Lee. P/ge,e. r 33 ft lid l.ft• J earvItt 6eY-'
Physical Address,City,and Zip 5 �; t d9 9 0 t1 \fr' ({l'sN ft' Pita ka1) .(2Aiii'
5M a 21.REMARKS �v
County �/ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - „
(if well field,one lat/long is sufficient) 22.Certification:
4 .) 46G4112, N 8I q Alt g 03S3 w `• 1 ,�
6.Is(are)the well(s):)(Permanent or ❑Temporary Signature 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 L° To ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown well construction information mid explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or an the back of this form.
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
(add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is need. Indicate TOTAL NUMBER of wells
drilled: - 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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')
6 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"1-"
Bit Off: S49uo 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC) t
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636 6
AIR ROTARY
12.Well 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 of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA O
PP`��� I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Q V Method of test: Ill V
13b.Disinfection type: 70%HTH Amount: Jt� OZ DATE SITE VISITED: i`� -a �
- __ _ VISITED BY:
Pri cry
Form GW- ironmental Quality-Division of Water Resources Revised 6-6-2018