GW1-2022-01800_Well Construction - GW1_20220214

+WEL+CONS T1RUC,TION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: i
.r0C& --3 0j=jnj=jV EE 14.WATER ZONES
Well Contractot`N a FROM TO DESCRIPTION
FEB1 4 2n??
ITT /81 ft 01 !11 cs /9fek
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NC Well Contractor Certificatiam.Numbe 15,OUTER CASING for multi-resedweIIs ORLINER da livable
YADKIN WELL COMPANY,INC. lnWM&W �U FROM To I)MMWM THIt3avEss MATERIAL
ft ft 1 L in.
Company Name Y°adW r 3 � r9� 7-T0X 16.nqM CASING OR Tus>r1G eothermal closed-loop) '
2.well Construction Permit#:
FROM TO DXMMMR TffiCIO�ESS MATERIAL (�
� i�� � e2.C.��� .mot
List all applicable well construction perms(i,e.UIC,County,State,Variance,eta - ft. ft e�3J II' aO*--V
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN r
pPy FROM TO DIAMETER SLOTSM TIHOCNESS MATEMAL
❑Agricultural Icrpal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) esidea l Water Supply(single) ft. ft. in.
❑IndustriabfCommercial '17ResideAbal Water Supply(shared) 18.GROUT
❑Irrigation bWells:>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. el-
❑Monitoring ;I•ORecovery I/ ft .Zy� ft,
N
Injection Well: r ft
❑Aquifer Recharge ❑Groundwater Remediation 0
19.SAND/GRAVEL PACK da livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI ACEMIINT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft -
05Tcrimenta]Technology 15Subsidence Control ft ft.
❑Geothermal(Closed Loop) bTracer 20.DRILLIlVGLOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) d6ther(explain under#21 Remadcs) FROM TO DESCIMMOx color,hordnrm,soilhnck -a sao,ete
STD-
0, 'ft o.
4.Date Wells)Completed: Z' Well IN A40. O d- R �ft e� s
5a.Well Loocation: /� Phone #3s��^ ���-.i►�C9�
14i V Are,�irr ft ft
Facility/Ovine 'erne Facility ID#(if applicable) ft ft.
604A COO ge-^
Physical Address,City,and Zip P� i
Mft
�/ I f -{/(I V\ ea,� 2L REMARKS
County a� .. Parcel Identification No.GM9)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees.
(ifwe0 field,one lat/longis sufficient) 22.Certification:
3C® 12' 17°' N S®0 3.C' 16 w
6.Is(are)the well(s): 2 ermanent or ❑Temporary Siggpromitim Well Contractor Date
Bysfgning thisform,l hereby eertffy that the wells)was(were)constructedin accordance with
7.Is this a repair to an existing well: ❑Yes or &PQo ISANCAC 02C.0700 or 13ANCdC'02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known 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:
B.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 Ovee in Remado;Box).You may also attach additional pages if necessary.
drilled:, l 24.Su9Mrrr L INSTRUCTIONS
9.Total well depth below land surface: of t// (ft,) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths!f different(example-3@200'and 2Q700D
SO. ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top bf easing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,u'se
11,Borehole diameter: (iu;) Bit Off: se9 72o 24b.For Injection Wells: Copp to DWI;,Unde;ground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY i/ -
24c.For Water Supply and Open-Loop Geothermal Return Wells:_Copy to the
(it.auger,rotary,cable,direct push,etc.) county environmental healtb d artment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci I s over 100,000 GPD:Copy to DWR,CCPCUA
•�13a.Yield(gpm) Method of test: I- O. " Permit Program,1611 MSC,Raleigh,NC 27699-1611 N
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13b.Disinfection type: 70%HTH Amount: L 02 DATE SITE VISITED: 12-A, dZ 1 •-