GW1-2022-00882_Well Construction - GW1_20220107

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TIT�&)TtOIS RECORD(GH-1) For Internal Use Only:
fl Well Coi tractor Information: Oe„k 1,45 14.WATER ZONES
FROM TO DESCRIPTION
•.Well Contractor
tN�ame ft. 10 ft• 3 460
ft. 3 3o ft. "(GQYW
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER TffiCLOVESS MATERIAL
YADKIN WELL COMPANY,INC. ft
!,Company Name ii7 ( �� b�� 3 f 16•IlVNER CASIIVG OR TUBING eothermal closed-loo
C FROM TO DIAhIE1ER THICKNESS MA /`^ter
z;w 41 ft ft &PA S�9,aI (�if�
11 Construction Permit#: `+ � I c/ rz
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.)
, ft. % in. (�
3.Well Use(check well use): I `
17.SCREEN
Water Supply Well: FROM -''TO DIAMETER SLOTSrzC TMCKNrSS MATERIAL \
❑Agricultural ❑__LMLunicipal/Public7(shared)
ft. ft. in•
❑Geothermal(Heating/Cooling Supply) dWesidential Water ft. ft. in.
❑lndustrial/Commercial ❑Residential Water 18.GROUT rq
❑Irrigation ❑Wells>I00,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® tt, 3 ft. Hak IQ povC'.J
❑Monitoring ORecovery ft a� fLoJSC(G�t'ovlg Pv ed
Injection Well: fL %
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a licable)
❑Aquifer Storage and Recovery ❑Salinity Ranier FROM TO MATERIAL EMPLACEMENT W=, OD
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control fL R•
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness seilhoek G m sae,cte.
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) fL
4.Date Well(s)Completed: 9, d Well lo#A� � `� ft �(��-rt F�dP t4f
ft ft.
Sa.Weu Location: Phone i 66
.—FQ y/Owner ame Facility ID#(if applicable);' ft. ft
� fL JAN 7 t202? ;
Physical Address,City,and Zip
21.RR.MARKR _
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficientl �( 22.Certification-
- W .'lam
Sign of Cfrtified Well Contractor Date
6.Is(are)the well(s): permanent 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 e:dsting well: ❑Yes or l$No 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#21 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 into
(add See Over in Remarks Box):You may also attaoh additional pages if necessary.
construction,only 1 QW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: �'�4 a (ft') Submit this GW-1 within 30 days of well completion per the following t
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources
10.Static water level below top of casing: 10 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
MOM �• 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636 1.
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:'Copy to't,h,,
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 1 a,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWRa�C,,
Permit Program,1611 MSC,Raleigh,NC 27699-1611 ,C aJ
13a.Yield(gpm)_ Method of•test: A i. _ c-�f
Y
70%HTH `1 OZ DATE SITE VISITED:
13b.Disinfection type: Amount:_—_ ---. VISITED BY:
--- t: