GW1-2022-01077_Well Construction - GW1_20220107

�L CONSTRUCTION RE CO (GW-1i For Internal Use Only:
1.We Contractor information:
fie,r �.� �'^5 ia.WATER ZONES
FROM TO DESCRIPTION
Well ContmowrName ft- �3 ft' t GP
A f� �1� it G Gt�r+'►
NC Well Contractor CeitificenonNumber 15.OUTER CASWG for multi-cased webs ORLINER if a livable
FROM TO D14DMTER rg[QQIESs MATERIAL.
YADKIN WELL COMPANY,INC. ft ft in.
CompatprName 16.E%4ER CARENG OR TUBING{eothern dosed loo
I'll�� �� d FROM TO Dranrtrs>u Tmckcp ss MATERIAL
2 well Construction permit#: / in. A,
List all°applicable well construction permits A-IIIC,County;St 4 Variance,etc) ft l j ' ft [�s!'� s +�� � f�
ft ft.
3.Well Use(checkwell use): 17.SCREEN
Water SuPpl1'Well: FROM TO DIAtvlErER SLOT SIZE iTHIC10%MRs MATERtnL
❑Agricultnra] ❑MunicipaltPublic
❑Geothermal(Heating/Cooling Supply) '�tesidential Water Supply(single) ft ft. fin•
❑Industrial/Commerciel A2
❑Residential Water Supply(shared) 18.GROUT
❑We1lS>100,000 GPl) FROM TO MATERIAL I�LACEMENTGTHOD&AMOUNT
❑Lai on ft' 1 ®k P1� Povr*d
Noll-Water Supplg Well:
❑Moniiolmg
❑Recovery .3 it• 102 1e Gr P�,�►ft _
Infection Welkr, 10
❑Aquifea Rediarge 0oroundwater Remediation 19:SAND/GRAVEL PACK zi a liesble)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERW. Ern LACEI�NT METHOD
❑StormwaterDranage
❑Aquifer Test ft S.
❑Exc erimentd Technology
❑Subsidence Control ft it
❑Geothemaal(Closed Loop) ❑Tracer I0.DRII,LING LOG attach additional sheets ifa
ryl
.PROM TO DESCRIPTION rotor,,hardness,saiUrorlc c, nia sizq cte
❑C}othermal(Hesting/Coolmg Retmm) ❑Other( lain under�121 Remarks) ® �, •*S ft elf -�
y f dW
IT
4.Date Wells)Completed: 1 Well ID#
.. ft. ft
5a.Well Location: Phone # /t- w ft. it
s� 4-1
.t ��e � ft ft.
IM(.if applicable)
Fam'FitYlOwnerName ft: ft
�q fL ft.
Physical Address,,M Bud p 21 REMARKS
_
Pasce13deatifioltioallo.(P1N)'
Courdy .
5b.-Latitude and longitude in degreesWnutes/seconds or decimal degrees: 22.Certification:
i (ifviell Feld,one lat/longis'sufficient)
Sigo o, ertified Well Contractor Date
6.16(are)the well(s):tAE]permanent or ❑Temporary;
Bysigningthisfarm,I hereby cartifythat thew011(s)was(wisre)'constructed in accordance with
15ANGAC 02C.0100 or 15ANC4C 02C.02001Yell Construction standards end that a copy
7.Is this a repair to an existing well: ❑Yes or l l of this record has been provided to the well owner.
if this fs a repoir,fd►out 7mv awn well construction informatlon d"erpxplain the nature of the
rrpatr under#21 remarks section or on the back of thisfonft. 23.Site diagram or additional well details:
You may use the back of ibis page to provide additional well construction info
8.For,Geoprobe/DFT or Closed-Loop Geothermal Wells'having the same (add'See Over'in Remarks Box).'You may also attach additional pages if necessary.
construction,only l OW-1"needed. Indicate TOTAL NUMBER of wells
e& 24.SUBMPITAL INSTRUCTIONS
drill
a. (ft.)
9 LP Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For mulftple wells tfstall depths Y'different(example-3@2oo'and 2Q1001
e � (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Units 1617 MSC,Raleigh,NC 27699-1617
Irwater level Is above casing,use"+'
Bit Off' �s 24b.For Injection 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
(i.e.auger.mtary,cable,direct push,etc.) county environmental health department of the county where installed
pR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test:
13a.Yield(gpm)
j �,;,. „T„ 1 t n7 DATE SITE VISITED: ;