GW1-2022-01029_Well Construction - GW1_20220107

FRCt.I TO L SC= Tit)R
Well Cant:actarName
'LA ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable
FROM TO DIAAgrl IrEncrcNni TERIAL
YADKIN WELL COMPANY,INC, ft ft in
Company Name 16.INNER CASING OR TUBING(96cthercial dosed-loop)
2.Well Construction Permit#: f/ ( 6 C Al FROM TO DlAlVMTER TffiCICICss IKUVRRnw
List all applicable well construction permits(Ie IIIC,County,State,Valiance,etc) ft ft' (/f�d in s a
fti ft. in. `
3.Well Use(checll well use):
17.8CP—r2 I
Water Supply'Well: rROhi TO Di:_tr1ETZ.1 SLOTSr�.E TniCI<]•t_SC i:]n7'ssri
❑Agricultural ❑MunicipaUPublic ft. ft.
❑Geothermal(Heatini/Cooliug"Supply) esidential Water Supply(single) ft. ft. in.
P]ndustrlal/Commeroial OResidential Water Supply(shalEd) 18.C-F.C1Ue
❑Wells>100,000GPD rnolti TO I:tA;cRSA� Frt;PLACEn•�NTr.�'THODc.+1:•IoulvT
PPh`
Su SIVel O 3 ft kale "Ra COUfec�
r ,
❑Monitotrrig ❑Recovery
M Infection Well: 3 a� �ICt 6r&A J
❑ uifer Recharge ❑Groundwater Remediadon { '
A4 ;9..4A,1DICK RAVE at,r�(d_mti6eble
❑Aquifer Storage and Recovery, DSalinity Barrier FROM TO rdATERLLL Er.IpLACeGx rr krE tiaC,D �1
�E)AqutferTest-' z ❑StocmwaterDrainage ft. `J
•OExpenrnental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) pTlacer 20.I)RiLLING LOG(attach 2ddiflonal sheets if necessary) ~�
y FRON TO DESCRIPTION color,hardness,soiltrocic e, n sae ate
❑Geothermal%eating/CoolingRrtain) [ Other(explain under#21 Remam " it c
4.Date Well(s)Completed: 14, Well M#/T11 "�l� o� eft' 13a3 R . "
Sa.Well Location: Phone # 7o i{,F7 w GGA' y
. t I eft
Gly�e• P6�� Pam( .arm
Facility/Owner Name Facility ID#(if applicable)Q�j(d Y ft
ft.
ft.. ft ^7
Physical:Address,City,and Zip fv'
21.RI+.]1SA.RKS L
Parcrll Identification No.(FIN) c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
3 6 � 2 N tra. .S® w ►z �� a ;fir
Sivalurc of ertified Well Contractor Date
6,Is(are)the well(s): ermanent or ❑Temporary
Bysignbigthisform,1 hereby certify that the well(k)was(were)constructed in accordance writ� §Y
7.Is this a repair to an existing well,. ❑Yes or Ao 15ANCAC 02C.0100 or 15A NCAC OZC.0200 Well Construction Standards and that
If this is a repair,fill out known well construction in d explain the nature of the ofihis record has been provided to the well owner.
repair under021 remarkrsection or on the barkofthisform. 23.Site diagram or additional well details: eJ
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
( See Over in Remark Box).You may also attach additional pages if necessary.
construction,only 1 OW.-1 is needed. Indicate TOTAL NUMBER of wells ,
l 24.SUBMITTAL INSTRUCTIONS
drilled: �
9.Total well depth below land surface: 373 (ft) Submit this GW-1 within 30 days of well completion per the following:
Formulliple wells list all depths ifdtjjerem(=ample-3@200'and2@1001 r
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3W (R) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
C® Bit Off: .dU 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC) ,,
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-'Loop Geothermal Return Wells:Copy to the'R,- e
(i.e.auger,rotary,cable,direct pitch,eta.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD_: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611ao :' j
13a.Yield(gpm) Method of test d(✓ - y /,y,( ��+
70%HTH 41 OZ DATE SITE VISITED: LL� tipA
136.Disinfection type: mount: 110
/
VISITED BY: /
F,,,,,,r1W-1 _North—Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 ,