GW1--06233_Well Construction - GW1_20230925

WEj ILL. .:ONSTRNCILION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
- Se Wokf As 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4-is-.) A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLINER(if ap livable) E
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft ! in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) %,‘,..,
2.Well Construction Permit#: ! ' ' c FROM TO DIAMETER TITICICNESS MMAATERIAI.
List all applicable well construction permits(ix.MC,Corm y',State.Variance,etc) �l ft 3Q ft (j�lti 'n. SDR*t PIP c (1
3.Well Use(check well use): ft' ft' m �{
•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ltesidential Water Supply(single) • ft. ft. in.
❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 2 ft. E/Ote' (u� Pecs ec 12 b SS
❑Monitoring ❑Recovery ft. ft. ' �-"_
Injection Well:
❑Aquifer Recharge 0 Groundwater Remediation '
19.SAND/GRAYEL PACK Cal applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier IrRoM TO MATERIAL EMPLACEMENT METHOD
11/Aquifer Test ❑Stormwater Drainage ft ft. .
DExperimental Technology ❑Subsidence Control ft" t;?ny'.ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#/21 Rematics) FROM TO' DESCRIPTION lesion hardness.sail/rockrypa grain svt etc.)
Zel ri(aS D ft .:10 ft Sot!
4.Date Well(s)Completed: 813s,33. Well ID# 4/4 11°�3 tea. 1 Q ft. 32 ft- G'q'qm`v
38 f �o ft' t'a�^ Rocr
Sa.VPellLocation: Phone# '7:J�- f0-• 34‘3'.
PP `re •qo ft !Roy,- Grh.I Aar
Facility/Owner NamePadiliiyID11(if applicable) -ft, ft r--255 :::".1,"'t ••i 4""'"-°�-%
,.:Physical Address,C ,an3'Zii I EMft ft. S E P 52 Q?
�� ) 21.R ARXS
f/ 0. 4 r �J _ Infor Alaf't+7 Pam--:%5 f:2 t;R
county Parcel Identification No.(10N) +r S.c 1-7
5b.Latitude arid longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 3li/long is sufficient) 22.Certification:
_3 ; 4)- 1-11 1R '' N 0 8/a ill ' Lis�w
�,�✓ °o ?I2s]23
6.Is(are)-the well(s): ermanent or ❑Temporary Signatu of L'erhied ell Contractor Date
�c, By signing thisform,I hereby cert(y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NC4C 02C.0100 or ISA NC4C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction bafarmalion d explain the nature of the of this record has been provided to the well owner.
repair under 1121 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 if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Igbi1 (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 2©100)
5"1, 24a. For All Wells: Original iform to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: �' (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaler level Is above casing,use"+" _ ile
Bit Off: 6 .051 1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�•) Program,1636 MSC,Raleigh,NC 27699-1636 d
a
AIR ROTARY
12.Well construction method: 24c.For Water Su I and 0 enLLoo Geothermal Return Wel o the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where i ed
FOR WATER SUPPLY WELLS ONLY: 1 a
24d.For Water Wells producinglover 100,000 GPD: C y to DWR,CC UA
I t Permit Program,1611 MSC,Raleigh,NC 27699-1611 !�
13a.Yield(gpm) �� Method of test: I . p
7D%HTH s.
oz DATE SITE VISITED: / (O- Z'
13b.Disinfection type: Amount: :�0..
I'
prir--P-.
VISITED BY: