GW1-2022-01808_Well Construction - GW1_20220214

L fc0lY$�1 1�J�TIaw_P t� � ��-�o For Internal Use Only:
A.Well Contractor Informntion:
cvt� (ns 14.WATER ZONES I'
- FROM TO DESCRD TION
Well Contractor Name y�
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NC Well Contractor Certification Number 15,OUTER CASING for multi-eased wells OR LINER if a ticable
YADKIN WELL COMPANY,INC. . ) Q1 Procoeoing Ulwl FROM To DIAMETER THICKNESS MATERIAL
w."M$a fr. ft. in.
We
Company Name
I�/ � 16.IlVNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: (� FROM TO DIAMETER TMCIGMS MATERIAL /
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) 4 f it IT ft / 1/y in. S 0r a i PVC 1`-}-ll
3.Well Use(check well use): fr. fr. [/ in. �-�-•
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL --
❑Agricultural ❑Municipal/Pubiic ft. fr. in. ILA
❑Geothermal(Heating/Cooling Supply) �Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT AL. d�
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERI EMPLACEMENT METHOD&AMOUNT _-- �
Non-Water Supply Well: v it' fr' Holle Pld Q0owA iI ba sit
❑Monitoring ❑Recovery h.' IL a I f- pftk Geovi PuMed 3 6450.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storruwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION coma,hardn�s:,:cNroek to sae ate
ft -1 ft.
4.Date Well(s)Completed: �'��:14 '•� Well ID# !TQ' ✓ -7-7 ft. 243 ft-
ft
�
5a.Well Location: Phone # 334-. 9i7 Pzl ('� �� ft. ft �V
Facility/Owner Nam Facility 1D#(if applicable) ft ft ...
NO o?UI ft ft j. ' i
Physical Address,City,and Zip ft ft
21.RE(ARKS ;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3 (13sPI G N �"1 /SS. /I w
�., COW-
6.Is(are)the wells)�Ikermanent or� .-❑Temporary Sign of a ed Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to in existing well:E ❑Yes or ANo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 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:
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 10 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 c©200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casting,use"+"
11.Borehole diameter: (�) Bit Off: .O l0 24b.For Injection Wells:Copy'to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY G1
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 DWE,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �_ Method of test: Q��i�
L13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: -Z
. _- -_ - VISITED BY: