GW1-2022-01806_Well Construction - GW1_20220214

_)NS 1ITON- 'C' ET' (a3IV-1) For Internal Use Only:
i.Well Contractor Information:
J«rtAS 14.WATER ZONES
FROM TO DESCRIPTION
Well ContsactorName ft. Q(' ft. —
a �` ,Sri.� ft.
NC Well Contractor Certification Number �,/ {Yf Li.+�• 15.OUTER CASING for multi-cased wells)OR LINER if a livable
FROM TO DIAMETE:t TffiCIOQESS MATERIAL
YADKIN WELL COMPANY,INC. L is 0n ft. fit. i°•
Company Name V6WINER CASING OR TUBING( enthermal closed-too
17� pro"Me+t UTO DIAMETER TffiCICNESS MATERIAL
2.Well Construction Permit#: ft. 1 'n- SDIRa1 PvC.List all applicable well construction permits(i.e. C,County,Smte, ft.3.Well Use(check well use): — �PlWa er Supply Well: To DIAMETER SLOT SIZE TMCICNESS MATERIAL
gricultural ❑Municipal/Public ft. ff. in.
❑Geothermal(Heating/CoOling Supply) Aesidential Water Supply(single) ft, ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) iB.GROUT
❑Irrigation ❑Wells>I00,000 GPD FROM TO MATERLU EMPLACEMENT 11fETHOD&AMOUNT
Non-Water Supply Well"
o ft. "1 ft. NG fC iP( Pouted
[]Monitoring ❑Recovery L4 IL Q I f• ouck &%wi 3
Injection Well: ft. ff.
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Stormwater Drainage ft.
❑Aquifer Test —
❑Experimental Technology ❑Subsidence Control fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessar
FROM TO DESCRIPTION color,hardness,soil/rock e, rain sae,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
We11ID#�!'t G�� fit 3.�1 ft. GCQt�r
r 4.Date Well(s)Completed: 5-
P 5a.Well Location: Phone # �Zt�— 3�Q `�l� it. fL \!
. e- /lQ 6L -
ft. fit
Facility/Owner Name Facility ID#(if applicable) —
�, ft. ft.
Physical Address,City,and Zip Of C fit. ft.
21 REMARKS —
69 County Parcel Identification No.(PIN)
�• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
s? (ifwell field,one lat/longis sufficient) 22.Certification:
Signa re of ed Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary
By signing thisform,I hereby certify[hat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )rNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill 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: \
You may use the back of this page to provide additional well construction info (�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box). Ycu may also attach additional pages if necessary.
construction only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: / 24.SUBMITTAL INSTRUCTIONS
3 9.Total well depth below land surface: 3aa -(ft*) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3Q200'and 2©100�
p1(� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fit.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use Q�
. Bit Off: L.00y 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(TUC)
( ) e�
11.Borehole diameter: In Program,1636 MSC,Raleigh,NC'
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 produciliover 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
Permit Program,1611 MSC,Raleigh,NC 27699-1611 L d 60
� Method of test: CG/Ll� 14
_.Lrf� Z Y
13b.Disinfection type: 70%HTH Amount: 'I OZ
DATE SITE VISITED: 3—
-
GU/ VISITED BY: zd
__..._.._.I' ent of Environmental Quality-Division of Water Resources Revised 6-6-2018