GW1--05231_Well Construction - GW1_20230818

a itl> CONS TR1JC ll UON RECORD d,GW4) For Internal Use Only:
1.Well Contractor Information:
ecy8y Pe- 19.WATER ZONES
TO DESCRIPTION
Well Contractor Name FROM , P
1g 131 ft. i Lib ft. lay �s9 '}�w - i,c,'NI Cleo,
ft. ft
NC Well Contractor CertiScahonNumber 15.OUTER CASING(for multi-cased weIlsl OR LINER(if a licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER , THICKNESS I MATERIAL1.1
ft. ft, in.
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop) (A
�d FROM TO DIAMETER T$ICICNESS MATERIAL.
2.Well Construction Permit#: i4 sg ,� '
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc) 'tc''1 ft. 1i,C4 ft b- in. p /,A P
3.Well Use(check well use): ft ft. in !_�1 �a
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) • ft, ft. in.
❑Industrial/Commercial - ❑Residential Water Supply(shared) 16.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: 0 ft a1/43 I ft. tatl C P5 t' ftAh l" a`i, f1.,
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft, ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#121 Remarks) FROM TO DESCRIPTION{color,hardness,soiLtrcektypc,grain sae etc.)
7-3I-aa ® ft. Vitt ft. 54 2°1
4.Date Well(s)Completed:e i-2a wen ID#' (® " �aay 1-1, � ftft' 4 5- 1h(.
5a.Well Location: Phone # 9f as 5"S"L i94 91ft' loa ft• 5 taro}e� f�
-� ,4,1 A .A ft. P31 ft yJ'vwr v-k-t \r,Gs() ii
Facility/OwnerName Facility ID#(if applicable) 13o ft' 19 a„ f.. g l f 66.'-4- -C
&14‘,/de.vines 4 04 e m 7 1 ft. a am
oo ft g ,.4Q -ol
Physical Address,City,and Zip aCe ft 905`ft. , ;}'2_ 60-et
° 21.REMARKS (71
a +�C�
County Parcel Identification No.(PIN) AUG5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: U 1 8 ZD23
(if well field,one let/long is sufficient) 22.Certification:
�p (g .,.?..e:1 Prnc.rd+D.rk 'R3
1 .2f 5fite).- N v °7, '3 w /p / a'Y4�+~ -�•.
6.Is are the well(s): ermanent or ❑Tem oary Signatureo Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or °L fo 15A NCAC 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 add explain the nature of the ofthis record has been provided to the well owner.
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'in Remark Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS 4
9.Total well depth below land surface: 2-10 (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')
C� ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5tatic water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+"
bit Off: .5:g13 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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,"
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
q,o Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 9 Method of test: 4,74. g
13b.Disinfection type: 70%HTH Amount: I� oZ DATE SITE VISITED: Ps, 7 'i '-2 f
VISITED BY: ad°
pri e�e
v.._raw-1 nental Quality-Division of Water Resources Revised 6-6-2018