GW1--02339_Well Construction - GW1_20240410

W LLCONSTRUCT11ION TEE CO D : W-'1)) For Internal Use Only: Ch
1.Well Contractor Information:
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11
t U.-043, 1 • e 19.WATER ZONES f
Well
ConhactdrName FROM TO DESCRIPTION
. 2 -I1 t? ? ft.- Iry?fr. i pi
NC Well Contractor Certification Number
15.OUTER CASING(for multi-ras� ells)OR LINER(if ap livable)
,YADKIN WELL COMPANY,INC. FROM - TO DIAMETER THICKNESS MATERIAL
Company Name ft. fr. I + in. ..�
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO •'DIAMETER THICK �'NESS MATERIAL
List all applicable well construction permits(Le.UIC, oun tat Variance,eta) �j ft. 1 O O . ft. 6vi 2.�'# in 1 179 �. f �tfis
3.Well Use(check well use): fr. ft. tn. '
Water Supply Well: 37.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑,Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in:
❑Industrial/Commercial . ❑Residential Water Supply(shared) 111.GROUT 1
❑Irrigation ❑Wells>100,000 GPD FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. /�6 ft. ,gym/-€t'% a S pa,,,a
OMonitoring ❑Recovery ft. �` ft. 3 1/ -s
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 '
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ' ft ,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) . . , .i .
FROM TO DESCRIPTION(color hardness,sail/rack type gram sae etc.)
.OGeotheimal(Heating/Cooling Return) DOther(explain under#21 Remarks)
4 Date: ells)Completed:,'�-S 1 j Well ID# s, r,'f� ®g' ft. ?C ft co , .64:dam^• ,�-, : .
Sa.Well:I.bcation: Phone # ®�5.-s97 7) J f. 4 Ca ft '�`� t_��.e`l_ .
4.
' ��. ✓ Yyt�,
ft. ft; �: j:'
acilijy/Owner Name FacilityID#(zfapplicable) ,; 4.:i' b L,.d, I, ; t', 4 • .
a a ; 1(0( ®� ft. ft: ti la s t ��
.8.�� ` '� � ® ` °Ill'',0f202't , 't
- gg 0 ft. ft.
Physical Address•sty,and,Zip '�� °�s�I`
21.REMARKS e' t Ii*' r+ ii? •v f R.ir' il
f V,/4't 4- 1r,,,,....1 ?.... `��+ ..,�`� -[.� ,e....-
County' ' Parcel IdentificationNo.(PIN) tlrl ��
t ._'
'7 5b.Latitude and longitude in degrees/minutes/seconds or decunal degrees:
(ifwell field,one lat/loiigissufficient) 22.Certification'
Signature of Certified Well Contractor j Date
6.Is(are)the well(s): ur ermanent or DTemporary { r p,
By signing thisform,'hereby cert fy that the well(s)was(were)constructed in accordance with,. ?';
7.Is this a repair to an existing well:- 'DYes or o " ''•.15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy'.r r
`'-;ro this record has been provided to the well owner. 3
If this is a repair,fill out known well construction information an explain the nature of the f p
• repair under#21 remarks section or on the back of thisform.'`a^
• 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 OW-1 is reded. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary'.
drilled: [� y ` 24.SUBMITTAL INSTRUCTIONS - P
9.Total well depth below land surface: '"1 A (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'if
2�100') i ..- •• �'
• ' v 24a. For All Wells: Original.form to Division of Water Resources (DWR), �•
10.Static water level below top of casing: .. (ft•) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617 t i
]Twofer level is above casing,use"+" /� /, �,r--
11.Borehole diameter: .6 (in.) Bit Off: 6 p G 30 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 41)
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
I NC 27699-1611
g, Permit Program,1611 MSC,Ralergh,I
13a.Yield(gpm) )@� Method of test:_
70%HTH a07 DATE SITE VISITED: e�� .,� jet=11.'-s "' Vie`,
13b.Disinfection type: _ Amounli.
Form GW.;1,'_;:
d 'ntp]Quality,Division of Water Resources Revised 6-6-2011