GW1--05188_Well Construction - GW1_20230814

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----:‘,33nTeliC CONSTRUCTION LEI.+-''•C0 ('GW1) For Internal Use Only:
1.Well Contractor Information: -
3
J�'j lI ,ldys 19.WATER ZONES
1 PROM TO DESCRIPTION
Well Contractor Name)r ® ft. ft. 0
d�iJ d l ft. ft
NC Well Contractor Certification Numher I5.OUTER CASING(for multi-rased wells)OR LINER(if a licable) ,#,
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THLCIOQESs MATERIAL
ft ft. in. N 1
Company Name // �] 16.INNER CASING OR TUBING(geothermal closed-loop) 5
2.Well Constr•uctionPermit#: 0/,6 5 / FROM TO DIAMETER THICIa ESS MATERIAL
all applicable well construction perms (i.e.UIC,County,State,Variance,etc.) jft• (.3 ft. G Sh in. , ley 6A1 v
ft, ft. in. 5
3.Well Use(check well use): P
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE mamas MATERIAL.
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) )(Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL' EMPLACEMENTMETHOD&AMOUNT
d ft, ,34 ft- -
Non-Water Supply Well: 1�®Qe �B� p�G Poured.- � Mr e
❑Monitoring DRecovery 3 ft G q ft &veg. &DA i vim'► IF �•+
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK(if applicable) - - ti
;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. '
DExperimental Technology OSubsidence Control • ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DIU LUNG LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hudaess,saVracktype.grain she.cte.)
❑Geothermal(Heating/Coolinge high) ❑Other(explain under#21 Remarks) 'V ft �,oi�!
I (e� p
4.Date Well(s)Completed: /1111 a3 Well lD# 'P 3 /0 ft vie 3 ft- 6 rows 16
Phone# 7 f-�39-r/� ft.5a.Well Location: _
ft ft e
�L9,�.trd s�iu.ere i(4g- c a-e013 -� -. (*
Paci]ify- #(if_applicable ft. ft. • 0 `:�., `( .r ti r C^"li e-'. �s
Facility/Owner ame ✓I ar�4 �Cl_� _ .. -
•
/„ ft- ft. _s
G./Oessly:l`se.,-- ��i, bir I. ft. ft AUG 1 °.'ZU23
Physical Address,City,and Zip a%1
��/ 21.REMARKS ++
County4 icet� Parcel Identification No.(PIN) Vote%a ier -D:Y`;`1/ -',-v'' - U.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one let/long is sufficient) 22.Certification:
• 3� vim' N V i 5 5 1 w 1{' D3
. 6.Is(are)the well(s): permanent or OTemporary
Sigiator or f Cued Well Contractor Date
By signing this form,I hereby cert fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15ANCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well contraction information ar I plain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the back ofthisform.
23.Site diagram or additional well details: •
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to p ovide additional well construction info . l
•
.construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: (. 2 24.SUBMITTAL INSTRUCTIONS
9.Total*ell depth below land surface: 14 8 3 (ft.) :`
For multiple wells list all depths if different(example-3Q200'and2Q100) Submit this GW-1 within 30 days of well completion per the following:
�� (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
If water level is above casing,use"t"
Bit Off: te •®1i `I 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IIJC)
11,Borehole diameter: on.) Program,1636 MSC,Raleigh,NC 27699-1636 1
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) I 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, •,.1
Permit Program, MSC,Raleigh,NC 27699-1611 t
13a.Yield(gpm) /� Method of test: evee c�'c ,�,�qq
70%HTH e,® OZ DATE SITE VISITED: :��, 1,^, ° b '�1
Amount: . s-
13b.Disinfection type: _ �y
r
. . , . _- _...____�-- ;• VISITED BY: 1,Ag •'i
F CP= omental Quality-Division of Water Resources Revised 6-6 2018 i
i Form GW-;;1._ �._ _ _. ._ -