GW1-2022-01789_Well Construction - GW1_20220214

VV EL L CONSTRUCTION RECORD (GH-1) For Internal Use Only:
1.Well
//Contractor Information:
14.WATER ZONES
Well Contractor Name PROM TO DESCRIPTION
J]�
RECEIVED -ft-
NC Well Contractor CettificationNumber 15,OUTER CASING for multi-cas ells OR LINER if a livable
YADKIN WELL COMPANY,INC. t� 4 2022 PROM To DIAMETER I TMCKU.SS MATERIAL,
ft. ft
Company Name PfM�V11� 16.INNER CASING OR TUBING eothermal dosed-loo )
2.Well Construction Permit#: 3 - ��� FROM TO DLAA=R THICIQYES5 MATERIAL,
List all applicable well construction permits(i,e.WC,County,State,Variance,etr-) ft. J ft �y t + ' S _
3.Well Use(checkwell use): ft• ft. to
17.SCREEN
Water Supply Well:
PP Y FROM I TO I DIAMETER I SLOTSIZEA TSICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water Supply Well: U ft. ft. h� Od V
❑Monitoring ❑Recovery ft. '� ft. n J
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVFS.PACK(if a livable)
❑Aquifer Storage and Recovery ❑SaliIlity Barrier PDRILLINGLOG
TO MATERIAL EA1P1ACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIMON color,hardness,soillrock type,grain sae,etc
ap
ft. ft.
4.Date Well Completed: Well ID#�/� � �� �ft• �.
5a.Well Location: Phone # • 'f0- 7qq to`Lft ,16 ,
If ft ft --
Facility/OwiAzNamee Facility
a ilityID#(ifappliicablee)) ft' ft
t'Cr �R� J iCJ`I. 2014(eS'l/Lkl� ft. ft. _
Physical Address,City,and Zip R ft. —
21. 11IARIGS _
County Parcel Identification No.(PIN)
04P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: moo
(ifwell field,one lat/longis sufficient) 22.Certification:
3 8 N
Signature of Certified W�Contmc�tor �� Data
6.Is(are)the well(s): �ermanent or ❑Temporary `
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PIo 15A NCAC 02C.0100 or•15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. (jl
drilled:, - rr�� 'J 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 110 7 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdifferent(example-3 00'and2©1000
So" Ia. 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"+"
Sit Off: 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
(Le.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 t!
13a.Yield(gP m Method of test: �f f' /
13b.Disinfection type 70% HTH Amount: r�y OZ DATE SITE VISITED:: 1[ Z l \p
tr- 4KAd VISITED BY:
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