GW1-2022-01809_Well Construction - GW1_20220214

P L,+CONSTRUCTION lRI �COR-D dGW-1) For Internal Use Only:
I.Well Contractor Information: C
lc(ns 19.WATER 20PIES �
1
Well Contractor Name FROM
�� ft. TO DESCRUTION
a IbIt'
��
NC Well Contractor CertificB=Number RECEIVED 15.OUTER CASING for multi-ca�ed*ells OR LINER if a licable �J
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TffiCETiEss MATERIAL p,�
FEB 14 R ft. ft. in.
Company Name 1 �.T.�w.. 16.INNER CASING OR TUBING' eothermal closed-loop)
2.Well Construction Permit#. d IDCI Pr'co r4 VrA FROM TO DIAMETER TffiCIINiSS 11ZLTER7AL
Lis/all applicable well construction permits(l,e UIC,Cournty, e(c) ft t 1!3 ft ♦ CAV in. � '� / 1 v
3.Well Use(check well use): ti' I.
1n. {'
17.SCREEN
Water Supply Well: FROM- TO DIAMETER SLOT SIZE+ TBICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Asidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 4011. 21 fL Corrcmic 90'Irej �2
❑Monitoring ❑Recovery ft ft.
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METBOD
❑Aquifer Test ❑Stormwater Drainage
a ❑Experimental Technology []Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Bettnn) ❑Other(explain under#21 Remarks) FROM TO DIZSCRIP71ON color,hardness,soiVrork grain sae,eta C
ft, /&SIL ;l
4.Date Well(s)Completed: I)V1.22-WeIIID# /05 R' p, "' 6 _
5a.�W.e�llLo�cationn: Phone # 3���6�«�3® R' fL C
{�JGi/{/B�(' A® F*� ft ft .�
Fa /OwnerName FacrD*ID#(ifopplicable) ft. ft
Physical
�Address,City,and Zip Qzcpw ft, ft
W ill
/ktr- 21.REAIARKS
County ( Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
P� AV ,G3.A 2 N -r/ &A37 54 7f W L a7
6.Is(are)the well(s): LA ermanent or ❑Temporary Signatn of Cettified Won ContractorFIE Date
By s/gning thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an ea .AAAA____....dsting well: ❑Yes or �Io 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Mondards and.that a ropy
1f this is a repair,fill out brown well construction information a4d explain the nature of the ufthis 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-1 is needed Indicate TOTAL NUMBER of wells (add See Over'in Remark's Box):'You may also attach additional pages if necessary.
drilled:, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 6J� (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf different(example=3(r�200'and 2©1001
14� ( ) 24a. For All Wells: Original !form to Division of Water Resources (DWR),
10.Static water level below top of casing: \_
ft. Information Processing Uni41617 MSC,Raleigh,NC 27699-1617
if wafer level is above casing,use"+"
11.Borehole diameter (in.) Off:_s',9gb 24b.For Injection Wells: Copy to DWI;,Underground Injection Control(IUC)-\
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 producin'g lover 100,000 GPD:Copy to DWF,CCPCUA 9
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm), Method of test:
a �1 DATE SITE VISITED: L "� 1
136.Disinfection type: 70/o HTH Amount: �d OZ ��
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