GW1--05146_Well Construction - GW1_20230814

vir ii-'CONSTRUCTION RECORD (GIW-1) For Internal Use Only:
1.Well Contractor Information:
y� 7 � 14.WATER ZONES
�vv J � FROM TO DESCRIPTION
Well Contractor Name
• 9.5 it ((®ft. /u (PIS
�� 1(45 ft. 150 ft �- 16 ply
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable) `
YADKIN WELL COMPANY,INC. .FROM TO DIAMETER THICKNESS MATERIAL !-
4 I ft. n .Cf ft 6.PS in. 5l€.a 1 foe -Company Name p� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: PP.lieL o I Go S-7 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.EEC,County,State,Variance,etc) ft. ft in.
ft. ft. in.
3.Well Use(check well use): ''T-`
37.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Eliejsidential Water Supply(single) ft. ft. in. (rho
❑Industrial/Commercial . ❑Residential Water Supply(shared) 16.GROUT Cv
❑In-igation ❑Wells>100,000 GPD FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: �r b ft. fa,s ft. RQ_,jy_ll/_Crgg ydwi e f 1r%%%e'-e
❑Monitoring --",8"4.1 ,, .LIC'1 v t ��+ r� t �3 �® ��v-'• _r r �. overy tt ft. r 6,55
Injection Well: ''e, ‘..r P...".'
ft. ft.
DAquifer Recharge h `r 3 j 2U23❑Groundwater Remediation Ig.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑SL�linity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• n : r`4 ...oSto�rmwater Drainage
ft. ft
❑Aquifer Test �,,-rN g
lihn▪o gyp+....i
❑ erimenta]Technology ❑Subsidence Control ft. it.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heatin CCoolingRe ) ❑Other(explain under#21 Remarks)
iP1e.,:r®' r i f"14Y/d ® ft. 10 ft 5p®,:/ iF je s A".�
4.Date Wells)Completed:tertj.Jy/e29 WellID# tl A 670 to ft' o91 ft' /hod '1 /.)v04 .,-.
5a.Well Location: r.. Phone # 9- ice-2( ka 1$ ft. eo tti -t-st
fb/1r("1) B RAF
Pike_ Te , d® ft. ,s ft. At /„. ~ /f1®v t .-s 4 t r Fac�lity/OwnerNaame FaccillityyID#(if applicable) ft• ft
ft. . ft.
R N �.ff i S:0...'Q),��,q L Si, �( FT6.l d� Co,i ft. ft.
Physical Address,City,and Zip s >S --(
��4��. �m ZI.�REMARi�S
County Parcel Identification No.(PIN) ' 7 I IA(( $ o/ C A g,1) A"°.' A t S 1-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifrcati',.:
,. , 2-1.3 7.3
4 N 't, `l-1 k3 / w ig (54-6/I V',93
6.Is(are)the well(s): l rmanent or OTemporary Certified Well Contractor Date
:y 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 19No ISANCAC 02C.0100 or 15A 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:
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'in Remarks Box).You may also attach additional pages f necessary.
drilled: I ?A.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2. (It') 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')
-t``\\ 24a. For All Wells: Original form to Division of Water Resources (DWR), ;
10.Static water level below top of casing: V (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwoter level is above casing,use"+"
11.Borehole diameter: (in.)
Bit Off: gi t� /3 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IIIC)
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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed W
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
IPermit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / Method of test: rt y_ pi..4) Ai -1- at
70%HTH OZ DATE SITE VISITED: �,02- ' 2_3 bra
13b.Disinfection type: Amount:
- - 3S
Pri rP I VISITED BY:
Form GW-1 onmental Quality-Division of Water Resources Revised 6-6-2018