GW1-2022-01790_Well Construction - GW1_20220214

'—� LL CONSTRUCTION RECORD (-GW-I) For Internal Use Only:
1.Wdl Contractor Information:
1'r, w G+�—1 n S 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
s s RI-CEIVED ft. laor ft. 3 61M
y .)A ft. :1y0 ft. 3 GPM,
NC Well Contractor Certification Number F E DD 1 4 20L
15.OUTER CASING for mulfi-rased wells OR LINER rf a LicaNe
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCKPIESs MATERIAL
ft ft in.
Company Name rAWUI
,,WOOOG
wtr7�vv/"£" �,/n 16.INNER CASING OR TUBING eathermal closed-loo )
2.Well Construction Permit#:��4 0j'.?D K!— !5/'f'�4 FROM TO DIAMF.-MR TEacKNrss i%,iATmuAL
List all applicable well construction permits r,e.UIC,County,State,Parlance,etc) t ft 8 ft
3.Well Use(check well use): ft• ft' in. J
17.SCREEN
Water Supply Well:
I7IOM TO DIAMETER SLAT SIZE TRICKINESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft: ft. in. �ss
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. r
❑Monitoring ❑Recovery ft a3 ft.
Injection WeJI:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cifa licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL 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) 7r
L
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rurk emft. -7 ft• sell j C
4.Date Well Completed: a `� Z� Well ID# 40` ft. o:) ft.
91
5a.Well Location: Phone # ft ft.ft.ft ft. /-'
bati;r,0- &P P le-
Fam7ity/Owner Name Facility M#(if applicablc) ft. f
S nulls �vrd ft.
Physical Address,City,and Zip al(013 ft ft
# ram_ koV 21.REMARKS
County f / Parcel Idenlification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3 5- N W
6.Is(are)the well(s):?Permanent or ❑Temporary SignatJ ol CertAfd Well Contactor Date
By signing thisform,I hereby ceritfy that the wells)war(were)constructed/n accordance with
7.Is this a repair to an existing well: ❑Yes or *No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WEll Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplafn the nature of the of this record has been pravided to the well owner.
repair under f21 remarks section or on the back of this form.
23.5ite 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 Ove in RemarIc Box).You may also attach additional pages if rinmsary.
drilled: 6 24.SUBN=AL INSTRUCTIONS
9.Total well depth below land surface: 3a,' (ft.) Submit this GW-1 within 30 days of well completion per the fallowing:
For multiple wells list all depths If different(example-3 c@200'and 2@100') �IJ
24a. For All Wells: Original form to Division of Water Resources (DWR), \
10.Static water level below top of casing: S (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use"+" / p
f Borehole diameter V In. Bit Off: S.q1 7 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) ly
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,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
13a.Yield(gpm) Method of test: f Y
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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c HTH (� _ D TE SITE VISITED:
13b.Disinfection type: 70/o Amount: