GW1--05127_Well Construction - GW1_20230818

iv~- JL CONS TR11JC T1l'ON RECORD CORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
..3 (.1 l/`744 t nS 14.WATER ZONES `
FROM TO DESCRIPTION �°
Well Contractor Name �p ,..9g45a� 1rta5 ft 1v'a f* 7'C) tM
NC Well Contractor Certification Number 1 Q S '9 ft . ® G P tM �
15.OUTER CASING(for could-cased wells)OR LINER(if ap livable) P
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THIrR MESS MATERIAL
ft it. in.
Company Name p 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 7 2 6 I FROM TO
D1AMrTE THICKNESS MATERIAL
List all applicable well construction perm its(Le.UIC,County,State,Variance,etc) 4,..1 ft CO ft 447p in. .'I gg 641 t.,
3.Well Use(check well use): ft ft. in. 15
Water Supply Well: 17.SCREEN FROM FROM TO DIAMETER SLOT SIZE THIC[O LESS MATERIAL
-
❑Agricultural ❑Munioipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) or esidential Water Supply(single) • ft. it in. n
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
I:Irrigation - ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOIIAT c
Non-Water Supply Well: ® ft. D64ft. i ,i Fi P 3s
:Monitoring ❑Recovery ft. ft. 7
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
PA S urfer Test ❑Stormwater Drainage ft. it
DExperime• ntal Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
k�tOM TO DESCRIPTION(ceder,hardness,oaWracktype,grain sue,etc.)''
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)ismia3 es
ft ®I ft. y��l
4.Date Well Completed: 1 i 3011 7 Well ID# �.:� ® el ft. 3 D2 ft. Ca($A t V r
:Sa.Well Location: Phone # 70V-7 ,
Q� ft ft (( L� ^
Facility ID#(if t a �s L.8 .i
•
Facility/OwnerName cable) ft. f
.?( !,.' e- Cvf`r�Vicie. ' e.ttP �t��P� ft. ft. a�Gl 2023.
Physical Address,City,and Zip ft. ft.
In Prrr, 1.; .ass'
21.REMARKS rAM0..r' s
A-tie:4R7 •
County:, Parcel Identification No.(PIN)
i
' . 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneelet/longis sufficient) 22.Certification: •
3' 6/46'4'75 N kS '$F7® 774'5 WuJe0 I
6.Is(are)the well(s): permanent or ❑Temporary • Sign ahte of OErtified Well Contractor
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes •or ArNo 15A NCAC 02C.0100 or I5A 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 it21 remarks section or on 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
construction,only 1 GW 1 is needed. Ipdicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D] (t) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(erample-3()a 200'and 2(4I00')
( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
ft• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+" yy
Bit Off: (60 9 24b.For Injection Wells: Copy to DWR,Underground Injection Control PC)
IL Borehole diameter: on.) Program,1636 MSC,Raleigh,NC 27699-1636
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 �
40 � Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: 47° .
70%HTH Amount: 9 OZ DATE SITE VISITED: ® -`� Ni r]3b.Disinfection type: - _
i VISITED BY: AB'Q
ter?mu ;ire-nmental Quality-Division of Water Resources Revised 6-6-2018