GW1-2022-03140_Well Construction - GW1_20220214

ZCONSTRUCTION (GW-1) For Internal Use Only:
I.Well Contractor Inforruntion: i
3e, w a-�k f'nf 14.WATER ZONES I
t�Well Contractor Name FROM TO DESCRIPTION
I4�
.aq FEB 14 Zn??
NC Well Contractor Certification Number 15.OUTER CASING forriuifi-cased wells ORLINER if a licahle
YADKIN WELL COMPANY,INC. IRtor �P�ros��cM�l U FROM To DIAMETER Tazcr�rEss MATERIAL
( iYo� ft ft in.
Company Name 16.INNER CASING OR TUBING isothermal closed-too I
2.Well Construction Permit#: i�t��Zc J !� �i/� FROM TO D*•a�+'M TMCIQMS MATEIUAL
List all applicable well construction pennies(ee EW,County,State,Variance,etc.) ft ft G in. QPC,Q V/
3.Well Use(check well use): ft ft. in. C'
J Water Supply Well: 17.SCREEN rn
FROM TO DrAMETER SLOT SIZE TEICIMSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. �/J
O ,❑Geothermal(Heating/Cooling Supply) iesidential Water Supply(single) ft
`DIndustrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d, ft, fI. a rP� r& 3
❑Monitoring ❑Recovery ft as ft � I —
1 Injection Well- ft fL Js
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rfa linable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
OAquifer Test ❑Stormwater Drainage ft ft
\\� 0134erimental Techn6logy ❑Subsidence Control ft ft
❑Geo themlal(Closed Loop) ❑Tracer 20.DRILLIIVG LOG(attach additional sheets if necessa
FROM I TO DESCRIPTION color,hardness saiVrucktype,grain sire,cte ..
❑Geothermal(Heating/CoolingRetorn). ❑Other(=x Iain under#21 Remada)
ft ft.
3 4= /�
4 60
Date Well(s)•Completed: 1 hb 12 Well ID# .46 %er� &o ft' 11ap ft an.
5s.WellLocation:r/4A-e3 Phone #���'A'.Z 31�XS ft ft
--fd®`lei ft ft
g
Facility/Owns Name F-2ity ID9(if applicable) ft. ft
fL
it-
Physscel Address,City,and ZiP ft ft
Cotmty Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O
(ifwell field,one lat/loagis sufficient) 22.Certification:
36 N W la 2
6.Is(are)the well(s): Vermanent or ❑Temporary Sigo a of Ctified Well Contractor Date
By signing thisform,]hereby cer*that the we/l(s)was(were)consh•uctedin accordance with
7.Is this a repair to an existing well: ❑Yes or 19No 15ANCAC 02C.0100 or 15ANCAC'02C.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 awner. z ,
repair under f21 remakr 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 mfo
constrtion,only 1 GW-1 is fiee�a Indicate NUMBER.of wells (add'See Oven in Remarks Box).You may also attach additional pages If necessary.`
uc
drilled: ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q dy (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdiffenenl(ermnple-3(a)200'and 2®100� y P P
24a. For All Wells: Original form to Division of Water Resources (DWR),.
I0.5tatic water level below top of casing: 3 n (ft-) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
lfwater level Is above casing,use
11.Borehole diameter: 5�_(in.) Bit Off: .962 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)~'�
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: " 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 91)
(Lt.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: �
Permit Program,1611 MSC,Raleigh,NC 27699-1611
"7 �� p
70%HTH OZ DATE SITE VISITED:- f a o �—..1 / r,d
13b.Disinfection type: Amount:
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