GW1-2022-01776_Well Construction - GW1_20220214

For Internal Use Only:
1.WeN Contractor Information: , L
Jemi W ai Ic.1 it -% 14.WATER ZONES J
17ROM TO I DESCRIPTION Ty
Well ContactorNaame /�
-1 57�/!1 ft 70 ft 12 a n
fL
NC Well Contractor CertifieationNumber __ 15.OUTER CASING for multi-rased wells ORLINER if a urahle
YADKIN WELL COMPANY,INC. r tB 14 Znz? FROM xo DLAMETER T.Ea=ss. MATERIAL
ft, ft. in.
Company Namc
P Otl ft.
16.INNER CASING ORTU73ING(geothermal dosed-loo
2:Well Construction Permit FROM TO DIA*'r= •tz�ciamss MATERIAL
Lis/all applicable well construction p its(i e.I7IC, ounty, ate,Variance,eta) ft �°` ft G /.*
3.Well Use(check well use): ft• ft. 1II' V
Water'Supply Well: 17.SCREEN
IMOM TO DIAMETER SLOT STLE TE ciCNESS MATF UAL
❑Agticultaral ❑Municipal/Public
❑Geothermal(HeatinglCooIing Supply) residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
❑Irrigation ❑Wells>100,000 GPD mom TO MATERLSL EMPLACEMENT7,0 &AMOUNT
Nou-Wzter Supply Well: Poofed .SbG
plYfoahiing ❑Recovery it ft QJIelt�jr011� uns e� �� �o
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAPID/GRAVEL PACK if a tieable)
❑Aquifer Storage and Recovery ❑Salinity Barrier rrROM TO MATERIAL MEP1 ACEMENTMETHOD
❑Aquifer Test.. ❑Stonnwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft it
❑Geothmmal(ClosedLoop) ❑Tracer 20.11RILLINGLOG attach additional sheetsifnecessa
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION comr,haranes,,se0/rnck a size�m
ft.
so ft. a r
.4.Date Well(s)Completed: I U)41a.2 Well ID# ®m6® O 242t rq n&e`
r .
:5a;WellLocation. Phone # ' — -9 �j r ft
y ft ft
`Facility/OwncrName FaaililyID#(ifapi icable) ft
Physical Address,CifnGid Zip s� ft
As 4e- zx.REMARKS
County Panel Identification No.(FIN)
-Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
�� 4 54 N W Q.....� W o+oifp— I 2`I 22
6.Is(are)the well(s): lbPermartent or ❑Temporary Sigoaturt of CdEfied Well Contractor Date
By signing thisfarm,1 hereby rerti)�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Pro ISANCAC 02C.O100 or l ANCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and erplain the nature of the of this retard has been provided to the well owner.
repair render 01 remarks section or on the back ofthis form.
23.Site diagram or additionalwell 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 Remerim Box).You may also attach additional pages if necessary.
drilled., 24.SUBNHITAL INSTRUCTIONS
9.Total well depth below land surface: iJ� 1 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths!f&ffirenl(example-3@200'and 2@100)
30 24a. For All Wells:, Original form to Division of Water•Resources:(DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use
Bit Off: J� 24b.For Injection Wells: Copy to DWR,Underground InjeotioriControl'(IUC).:
11.Borehole diameter: (in.) Program,1636MSC,Raleigh,NC 27699-1636
AIR ROTARY
12,Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to'the
(i.e,auger,rotary,noble,direct push,ctn.) county environmental health department of.the county where installed
FOR WATER SUPPLY WELTS ONLY: :24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CC.PCUA 1:
13a.Yield(gprn) �' Method of test _ q Noun Program,1611 MSC,Raleigh,NC 27699-1611
70/o HTH OZ DATE 51TE VISITED:
y a n �.2�^
13b.Disinfection type. Amount j:i
VISITED BY:. `i rj
-Pri ra �_
Form GW-1 North Carolina Deoartinent ofEavironrimental duality-Division of Wafer Resourrr_s R ry cu l F_F_�n 1 A