GW1--06056_Well Construction - GW1_20230921

" 'WELL CONSTRUCTION 1 CO] (GW-1) For Internal Use Only:
1.Well Contractor Information:
•
� 0
CL LiA ill vs . 19.WATER ZONES '
FROM TO DESCRIPTION
Well Contractor Name
71-97.
ilreet
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased we➢s)OR LINER(gap licable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER .. THICKNESS MATERIAL
ft. ft. I , in.
Company Name ® 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: (°"'1�� , FROM TO DIAMETER , THICKNESS
MATERIAL - _
List all applicable well construction permits i.e.MC,County,State,Variance,etc) 4 1 ft cri ft 1,ri)Au• Sae-)9 p($v
IWell Use(check well use): ft ft.
17.SCREEN -�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL `
❑Agricultnral ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) tIblesidential Water Supply(single) - ft ft. in.
❑Industrial/Cornmercial DResidential Water Supply(shared) 18.GROUT n
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMFLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. .' ' ft. 56?,eikid rdreof
❑Monitoring DRecovery �' ft X'''' ft' g la p ro
Injection Well: R, f.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Test ❑Stolruwater Drainage ft ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,l,.udaess,soi0rocktype,grain sue,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#/21 Remarks) t
' ft � ft. I/
4.Date Well(s)Completed: S�'�'' 73 well 1D#/460-'9 " g42 R. 9.5" d ft f 065/ e,.s'¢
5a.Well Location: Phone # fed 4 ®-4/di `/S f' ?'t ,vI'd"" 1-e 11 `J
ft ft e'
�l� /d1�6%/Aat�
Facility/p0 ner aammes Facility Dti(if applicable) ft. ft ^^,i ^z:! ;i, f ',`7
Al ®�rc' .cis-/l�d``�'d�r ft. ft. $ �.�'�,s�$ 4" Y"L.,�
Physical Addis,City,and Zip 21 S E P 2 :+:.;2 0 23.REMARKS oo
4 d 4e., In oiw4rt/ -n Prr,:-..casing Urfa 3
County Parcel Ident cation No.(PIN) IJr;C.r`�CCr �./
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field,one lat/long is sufficient) 22.Certification:
3( / 7€ t?3 N WI 01.3a 5.cf(8" W , f, eee-Now .4)6.Is(are)the well(s): permanent or ❑Temporary
Si a of C ed Well ontiactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 1
7.Is this a repair to an existing well: ❑Yes or Ago 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a ropy 9.3
If Ihis 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. Ua
repair under#21 remarks section or on the back of thisform. 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 if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
s
9.Total well depth below land surface: 392. (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(Q200'and 2©100')
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
If water level is above casing,use"+"11.Borehole diameter: 6 (in.) Bit Off: 6.111S 29b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
. Program,1636 MSC,Raleigh,NCI 27699-163 6
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 WET S ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
,pp a of./ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) l�,/`' Method of test: 6s" ���®
13b.Disinfection type: 70%HTH Amount: B 0Z DATE SITE VISITED: l
_ VISITED BY: ��
Price- _ -
Form(iW-1 mental Quality_Division of Water Resources ' RP.�crd 6_6-miR