GW1-2022-01774_Well Construction - GW1_20220214

CONSTRUCTION RECORD GW--' For Internal Use Only:
1.Well Contractor Informationn:
l {. 14.WATER ZONES -
FROM TO DESCRIPTioid
Well Contractor Name ` t. C� ft. 'i
RECEIVED J J T'
T. -ft. t* i✓�� f
NC Well Contractor Certification Number 2� 15.O ER CASING for multi-ca wells)OR if a ble
YADKIN WELL COMPANY,INC. FROM TO DIAMETE2 THICIUMS MATERIAL
ft. ft, in.
Company Name it la7,w*r`•P►>yewwp Uti 16.INNER CASING OR TUBING(geothermal closed-loop) -'
2.Well Construction Permit#: FROM TO DIAMETER TffiCIINFSs MIATERLIL
Lis[all applicable well construction permits(t�,County, Variance,eta) r ft (,� ft' w �n' f ��(3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DGMETER SLOT SIZE THICIO
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. \
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
❑IIrI atioIl ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 4-7
Non-Water Supply Well: 0 it. -? C Fl �� �� n t
❑Monitoring ❑Recovery ft. ^LL ft.
Injection Well: ft. ft.
(l% ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERL\L, EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. -
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIF TION color,hardness,soilimek type ''tin sae,etn
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) -
J G z r '£.✓i1 C
J 4.Date Well(s)Completed: )7 `�( Well ID# AAB- 6G'; S_ft.
5a.Well Location: 11 PhOne # 3 i-�i 3'�Dd93 ��- ft �' yyf� `,'',
1iO e QiI� l - 'ft. �/ ft
T Facility/Owner Name acility ID# if app cab weler ft. ft ?C!)
�/ /7�(` ft. ft. v
C "33" �x n" for,.tc�,NC M
' ft. ft.
Physical Address,City,and Zip
4 21.REMARKS - V"
G ra trry
County Parcel Identification No.(PIN) -
�° 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
S (ifwell field,one Wilting is sufficient) 22.Certification:
Z.0 3 0 N VD 6-4 0 W E �- -
+\ Signature of-Certified Well Contractor Date
C-ts(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 existing well: Dyes or *0 I SA NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a ropy
/f this is a repair,fill out]mown well construction information and explain the nature of the of this record has beenprovided to the well owner.
repair under#21 remarkasection or on the back of thisform. 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i 24.SUBNIITTAL INSTRUCTIONS
` 1
9.Total well depth below land surface: [-r� (ft.) Submit this GW-1 within 30 days of well completion per the following: (�jJ
For multiple wells list all depths ifitfferent(example-3 a0200'an 2Q100D
(ft.) 24a. For All Wells: Original fcrrrl to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 p
If water level is above casing,use"+" /J
Bit Off: 1 LI 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 Opera-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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Qe1N
o DATE SITE VISITED: v -_tore-al
13b.Disinfection type: 70 h HTH Amount: OZ
-_- - VISITED BY:V-
tment of Environmental Quality-Division of Water Resources Revised 6-6-2019