GW1--06884_Well Construction - GW1_20231030

4 S
VVE L CONSTRUCTION iTE00 (G W-1) For Internal Use Only:
I.Well c.atractor Information: FT
4i I 14.WATER ZONES I ' ...
d FROM TO DESCRIPTION
Well Contractor me
. 3o3 A 41.10 ft. a21i1
ft. 9 �I1, •°39 - 62 nf.--
•9�� ft. ,Is , ft.,P I
NC Well Contractor C .•cation Number �C ® .�
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licahle)
YADKIN WELL COMPA ,1NC. FROM TO DIAMETER TRIMNESS MATE
ft / ft.
Company Name `'
8t7I f`t 16.INNER CASING OR TUBING(geothermal closed-loop)
�� 2.Well Construction Permit#: ' "1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perm, (i.e.'UIC,County,State,Variance,etc) T ft I R ' 6 i®1 in. ,S4Dg.-.4 q i VC,
3.Well Use(check well use): [ ft 4 ft' in.
Water Supply Well: 17.FtROM E TO DIAMETER SLOT SIZE TSICKNESS MATERIAL
❑AgriculturaI ❑',unicipal/Public ft> ft. io - A
❑Geothermal(Heating/Cooling Supply) ❑Res •ential Water Supply(single) / "-' ft, in. �- .O.r�
❑lndustrial/Commercial . IgItesid . al Water Supply(shared) 18.GROUT •
❑In-igation ❑Wells>14 1,000 GPD FROM TO MATERIAL p EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /ti ft. 2s." ft- 48,44gAiit O ► 60- i•, it tw,
DMonitoring ❑Recovery " V ft. ft.
Injection Well:
ft. ft.
❑Aguifer Recharge ❑Groundwater Remedi•,:on ,
\ 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 OSubsidence Control \\ ft
OGeothermal(Closed Loop) ❑Tracer \ 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(calor,hardness,soiUrack type grain size,etc-)
❑Geothermal(Heating/CoolingRearm) ❑Other(explain under#21Remarks) ,
/� 1 \ 4 ft. 70 ft, Sal/ : C.GA9a(,G� , k :&' J
4.Date Well(s)Completed: /0' t1'13 Well ID# (44 !g-le ye \,e; go4,
ft. � ft ���,��
5a.WellLocation: Phone # �1.28 '7-78-.5-01� fr. 1.- -- `-- ; -
19i'VI frr di/d ` is ea'6 -,
ID# 0 R.,
Facility/Owner Name Facility (if applicable) ,.ft. \ ft. 1
/�1Cr 9
Physical Address,City,and Zip r: , •'P i ,-Y
21.REMARKS ,.
/yt � ¢
County �/ Parcel ldentificationNo.(PIN) d G�.ens 6 I®�p 64 \ -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r��1a5 �.�lo/:<.ne.ai ,` e1,9.5i4f a'- g OttdlAi
(if well field,one lat/long is sufficient) 22.Certification:
4 t3. t 3" N IP/ •2,4,1_.cr44/ W
6.Is are the wells: ermanent or OTemporary /01:" --1 -X \ /0;•-i 7'a23
Signature of Certified Well Contractor \ Date
O O
• By signing thisform,I hereby certify that the we,s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or pjlo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 ',ell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
You may use the back of this page to provide\a:.'tonal well construction info 5
(add See Over'in Remarks Box).You may also atta',additional pages if necessary. <
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of-wells \ ,
drilled: I24.SUBMITTAL INSTRUCTIONS - if
9.Total well depth below land surface: 6 / (ft.) s.Submit this GW-1 within 30 days of well completion pe he following:
For multiple wells list all depths if different(example-3Q200'and 2Q100) j
24a. For All Wells: Original form to Division of Water' esources (DWR), 6)
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1."7
Ifwater level is above casing,use"+" �r C�® g \
11.Borehole diameter: f (in.) Bit Off: , 0 Z. 24b.For Injection Wells: Copy to DWR,Underground Injectio\Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c,For Water Supply and Open-Loop Geothermal Return Wells:`opy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed s,
O
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
f Permit Program, MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: aG tY
13b.Disinfection type: 70%HTH Amount: oz DATE SITE VISITED: [ "`/ -.2..3
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