GW1--05336_Well Construction - GW1_20230818

WELL CONSTRUCTION.UCT11tON RECORD(G1/11-2.) For Internal Use Only:
.-7.-,.....---
,,,,---
1.Well Contractor Information:
_ eeCs'if IRYNS 14.WATER ZONES .0
• FROM TO DESCRIPTION
Well Contractor Name 1( /3 ys it. I/7 ft. h � /ro 4 ��• 6/%/
� � !/ ft. ft. ! 'mod l!
NC Well Contactor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(if ap licable)
YADKIN WELL COMPANY,INC. FROM ' TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name 631 11161 ' c. / - 7 Q;y 16.INNER CASING OR TUBING(geothermal dosed-loop) P
2.Well Construction Permit#: C.p r y FROM TO DIAMETER THICKNESS MATERIAL3
List all applicable well construction permits(i.e.fAC,County,Slate,Variance,etc) it ]0?ft. in.
/W ® :PVC
ft. d
3.Well Use(check well use): ft. in. s e/C�
17.SCREEN t��
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL `
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) i@l(esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT r�
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: ® ft. �g0 ft. Rea ci i,-R g 6.55
°Monitoring ❑Recovery ft. �6 ft. eT
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 ❑Stormwater Drainage ft. ft.
❑Experimental Technology • ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) 170ther(explain under#21 Remarks) ft RSrti `
9 y
4.Date Wel](s)Completed: We11ID# ft �� ft- 5NR:s g c
5a.Well Location: Q Phone #79y_41sj®Q2-,I-� 02
ft. ft. o
�adl0� S te. ( 7) ft 1. ft. �_ct- p8htg R Y"
fI •
Facility/OwnerName / Facility ID#(if applicable) p ft. 340 ft. siirOsIbtiri i ii
Physical Addax's,City,and Zip 421111 ft. +� ft.
4 6 a12•1 21.REMARKS .-- -
County Parcel Identification No.(PIN) t '® V "Q V� E L
. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AUG 1 d LCLJ
(if well field,one let/long is sufficient) 22.Certification: 74
.®
3C. d M�
A 1"1 N 1 /. 29- /®'r W L� at'.rai_.n Pr^-4424 i llr�l j2
• Signature of Certified Well Contractor Date
6.Is(are)the well(s): CPermanent or ❑Temporary
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: ❑Yes or 11No 154 NCAC 02C.0100 or ISA 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-Loo 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 if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: tog (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"4"
Bit Off: ���1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (iD•) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY 1
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
• ,4I Permit Program,1611 MSC,Raleigh,NC 27699-1611 8
13a.Yield(gpm) 50 Method of test:
p` CI t
70%HTH Amount: IS OZ DATE SITE VISITED: y�
13b.Disinfection type: t
---- VISITED BY:
Pr rc 'T
Form GW-1 I mental Quality-Division of Water Resources Revised 6-6-201 H