GW1-2022-01154_Well Construction - GW1_20220103

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7�OFOJHERMAL WE CONSTRUCTION RECORD
WELL CONSTRUCTION ION CO" 9 r Internal Use OMW:
This form can he used for single or multiple vtells
.1.'Well Contractor Information:
ty 2 14.WATER ZONES
�/(I/A g,A 1 L J grow w er AFROM I.TO DESCRIPTION
Wall ContracLm Name d�V ft. �' 1 1 I.
P^'1 q„N
NC Well Contractor Certification Number 15,'OUTER CA IN for imilti-tnsrtfwells ORL R if a licable
K TO [ETbR TITICI 11 LAL
Yadkin Well Company, Inc. ft.
Company Name 16.DM r As mffl OR•TU L`1G( eot4eimal closed-Imo
1 / FROM TO DIAMETER THICIOPESS T"TLRLAL
2.Well Construction Permit#: I06—io( N Es , ft. Z� it, "�"�M n• f �, ,' tr S�
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List all opplieable well cotu0,lctlon permits(Le,CornHy,Stote, frm•lmrce,etc.)
ft, ft.
3.Well Use(ebech well use): 17.SCREEN
Water Supply Well: FJWAIJJ� TO AMLTEit SLOT SIZE li UMSS MATLRIAL
❑Agricultural ❑Municipal/Public n,
❑Geothermal(Heating./Cooling Supply) DResidential Water Supply(single) fit' •in'
0Industrial/Commercial GResidential Water Supply(shared) 18.GROUT
FROM. TO MATLRLAL FaMPLACEMOT METHOD&AMOUNT
li7Monitorm,
o
ovSupply
e
N -Water SuPp Y
1 Well
:. ,i ,. ... .. �Cl Govery - L..�-- - �sRfYh ,CX
R ft
.. ..... ....... -l. .. :1.
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❑Aquifer Recharge ❑GroundwaterRemediation 19,SAND/GRAVEL ACIC ifa licable
FRO f TO. - -.. ..-.MA'I1r.RIAL....._..._.....LhtPL4CLMMTMLTH0D
,�Aquif&Storage and Recovery 08alinity Barrier
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El Aquifer Test' 17StonnwaterDrainage
., '- fit.: -"':_: �_.:•.._ .. __. --- - -..
❑Experimental Technology �. ❑Subsidence Control
}. ARILL GIOG attachadtlida-alsheetslfvecessar
veo[herrnal'(Clo'sed Loop) t o i/k ❑Tracer FRoM T D1SCRrPTIOM(eolm hmdness soillroth e,grainsize,etc.
0Geothermal eating/CoolinglZehun ❑Other'(explainunder#IfRemarks it,, " "- t:,;" •."+' lac ""-"
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L �� T. T L `i7._ 7 tt iTI'v iP a m
4.DateWell(s)Completed: ••/'""6.,,-, Weubiv '1 o— 7%" J 1��
52,Well Location: Phone .nllmb,erQ- r'.�
ip 1 it. •I p ft,
1, 1 J I F n t7t '.r.�t i' L Gs Ps !
Facility/Owner•Name 1'acility IN(if applicable)
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:s (�,�(t's t„(�� w��j� l a C, 5 l �t. ft.
Physical Addrass,City,and Zip 21 REbfA11I:S
Iles t-h (`-�� _)
County Parcel Identification No.(PIN) Of ZOO S er Bore 1)]a e Of 100;5T111,
5b.Latitude and Longitude in dogrces/minutes/seconds of decimal degrees: 22,Certification: Li V(i£well field,one lat(loogT suf6clent)
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Signature o£Certified Well Contractor Data
6,Is(arc)the`vell(s): 146rmanent or ❑Teltipm'aly By signing rids form,I hereby cerlt�that the uell(s),Iras,(utere)copstnreted fti accordance
wlth 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Commiction Standards aild that a
7.Is this a repair to an existing Nell: OYes'',or lo copy oftids record has been provfded.to th¢li;all orytint .
Ifthisis a repair,fill out hiblivi well constniction fir formation and explahl the nattare ojthe
yepairtnider 2lremmkrsecfio)toron the back ofthisfomt,
Xou ma}'use the back of thjs.page to provide additional well site details or well
li..Numb ar,of.wclls,constr6cfed;. construction details, You mayaiao'attacliadditronalpagesifnecessary,
For,inultiple it jectioat armor}rater sirpplywells ONLYcultic the'same cottsMneUoti;you can
subutft one for•nr, SUBMITTAL INSTUCT10NS' '•; _
9.Total well depth'below land surface:, � �� _(ft.). 24n;:Eor All 'Wells: . Submit this form with in30 days of completion of well
For multiple wells list all depths ifdferent(exainple-9©200'midy2/Q,i00) construction to the fallowing: p ,
10.Staticwatcr level below top ofcasing: / V (ft.) I)Msionof Water ounlity,Information Processing Uniti <—AN
Ijivater level is above coring,:rse"+" 1617 Mall Service Center,Raleigh,NC 27699-1617 ,
11.Borehole diameter: 6 (iu.) 24b,Z+or Iuiection Wells: In addition to,sending the form'to the address in 24'a
above, also,submit a copy of this form williin 30 days of completion of well
12.Wall construction method: Rotary. construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centar,Raleigh,.NC 27699-1.636
13a,Yield(gprn) �•. Method of test: rT� air 24c,PorWater Supply&IniectionWells' In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
f U completion of well constriction io the cotmty health department of the county
13'b.Disinfection type: HTH Amount: t where constructed,
A-6 4'ru
Form G W-1 North Cazolina Department of Environment and Natural Resources—Division of Water Quality Revised tan,2013
Da't0 site vi5; + ed: j- - � By: 0