GW1--05121_Well Construction - GW1_20230818

eL 3COI TS. '11JCTIION PJE CtO] D(GW-1) For Internal Use Only:
e--I-Well Contr for Information:
90t�W , 19.WATER ZONES
� � FROM TO DESCRIPTION
Well Contractor Name -
3 ft, 2 33 ft. i 710I Va.
NC Well Contractor Certification Number 15.OUTER CASING(for Multi-cased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM TO-- alAMETER THICKNESS MATERIAL.
Company Name �,/1 C/ 16.INNER CASING OR TUBING(geothermal dos -oop) V
2.Well Construction Permit#: 16 6 J 55 FROM TO DIAMETER THLCICN Ss MATERIAL '40
List all applicable well construction permits(i.e.IIIC,County,State,Variance,etc) J" , 26 ft G-72 in. O� p Se (, / q^, a 7)
3.Well Use(check well use): __+.� 6 ft R' in.
` (J Q Gpl -Du,-
j»��� 9�`v' 17.SCREEN ��a/�/�q. �',(.r i. Z
Water Supply Well: cam-
1111CM TO DIAMETER SLOT SIZE THICIOVESS MATERIAL
❑Agricultural ❑Municipal/Public ckV ft. ft. in.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft f*` im�� ��
❑Industrial/Commercial DResidential Water Supply(shared) 18 GROUT q,
❑hrigation ❑Wells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .�
Non-Water Supply Well: ) ft: 11 ft. ni Cersy 449 J11 U
OMonitoring ❑Recovery I/ ft. ft. `"� "
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsideubsidence Control ft. r.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrocktype grain sue,etc.) p
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
..-S4- 6 z4 ot3 e7 0 ft. /2.0 ft' 50/(�, j L G � ,/1 .i
4.Date Well(s)Completed:Tr/3/23 Well ID#/4. 4 f-4/3 /Zip ft ft.ft. M.1J 6 e-.1 isig O
5a Well Location: . Phone # 73C=4%20•f O `rI° ft. I L®3 ft Mai,.4 (rc J�%, a. 01 So'�. 7
3-3
' Lgc,v-e / c wrAs Aril r4 G•aGt ft. s��
Pacfity/OynrerName ✓ Facility iD#(if applicable) ft. ft j `k,t rI
rT c i' kr 4 4 4' -1 Pee, l ft. it it , ' r' �p +��,.�.. z
Physical Address,City,and Zip Pee,
r ft ft. A U U 1 O 2023
' u
21.REMARKS
/t dntorir,r loco rr^caesing Ura
/� I
County Parcel Identification No.(PIN) �' ^f r Lrc f" [C'i' rv"-0=
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification: Z
;?6 °‘ J il o /$ IN 81 o 33 P 7 I w / � °- 3' Z 3
tr
6.Is(are)the well(s): Permanent or ❑Temporary Signainre of Certified Well Contractor Date
C By signing thisfarm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Qo_..•' 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy -i
If this is a repair,fill out]mown well construction information and explain the nature of the of this record has beenprovlded to the well owner. .l
repair under#21 remarks section or on the back of this form. ...0
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 is needed. Indicate TOTAL NUMBER of wells (add See Over'hi Remarlrs Box).You may also attach additional pages if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /a?0 3 (ft.) -c
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: -76 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), N
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
IL Borehole diameter: 6/ (in.) Bit Off: 6, /07 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
le Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Xield(gpm) � Method of test:
13b.Disinfection type: 70%HTH Amount: L®,' OZ. DATE SITE VISITED: Li"'s�.'"��
ir.PrP�
- - _ -1 VISITED BY: 148
Ferro,SW--1 Inmental Quality-Division of Water Resources Revised 6-6-2018