GW1-2022-03141_Well Construction - GW1_20220214

: + SONS 111T UCTI+ON RECORD(GW-1) For Internal Use Only:
I.Well Contractor in--formation:
Q J' -3 14.WATER ZONES
Well Contractor N e FROM TO DRSCRIPTION
D572-A FEB 1 4 2077 /ITI ft 01
NC Well Contactor Certification Number .�•3� a)3 5 l P q
15,OUTER CASING formulfi-casedwells ORLINER tfa livable
YADKIN WELL COMPANY,INC. lnbwaw FfaC��MOC►V RatoM CIO
aRAMI:TER THICLQVEss MATERIAL
DWOIK* fL fE' in
Company Name )°a tW n 3 X-F#q x 7903 16.DiNER CASIIVG OR TUBING eothermal closed loo
FROM TO DRAMETER MUCIaMS MATERIAL
Z.Well Construction Permit#:0 1 3�� � i+2C�.�1
List all applicable well construction prr7n1(s(?.a UIC,County,State,Variance,eta)- 1 - 1 T.9 I/O./>31"u. SJ)*1( I Por.
3.Well Use(checkwell use): ft ft' in.
Water Supply Well: 17.FROM SCREEN TO DIAMETER SLOTSM TRIIOCNEss MATERIAL
❑Agiicultura] ❑M icipal/Public ft. ft. in. �t
❑Geothermal(Heating/Cooling Supply) esidea l Water Supply(single) ft. ft. in.
❑lndustriallCommercial ?IMResideRibal Water Supply(shared) 18.GROUT
❑Irrigation ',QWells.>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: A, ; 0 ft tt. !N'.dk; pavriv
❑Monitoring "Mecovery t/ ft .Zq' ft. N St u M
Injection Well: r ' ft ft
❑Aquifer Recharge ❑Groundwater Remedistion
19.SAND/GRAVEL PACK rf a 'IIcable
❑Aquifer Storage andRecavery ❑Salinity Barrier FROM TO MATERIAL E117PIACEMRNTMETHOD
❑Aquifer Test OStormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) OTr'acer 20.DRILLING LOG attach additional sheets if nece:sa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DRSCRIPIYON color,hudnen,sail/mcklype,gmin sae,etc
4.Date Well(s)Completed: lo' 'L weu ID#A40. O'Td- F R' 1•ft ov a� , /et�.•�
Sa.Well L�oeation: Phone #,I ,- (02.,S%O
f ft &
rE fti
Facility/Own ame Facility ID#(if applicable) ft ft
Ft a ���.� e,�- rz-qS1- d ft. ft
Physical Address,lady.and ZiP r7 o Il V ft ft
21.REMARKS
County {/( ., Parcel Ideutifir4onNo.(PIN) to I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one lat/longis sufficient) i 22.Certification:
'3 0 12,` f 7'' N . 80® 3-C' l6 b- a
6.Is(are)the well(s): M ermaneut or ❑Temporary Sign of wcff Contractor Date
By signing this form,I hereby ceri#y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an e3dsting well: ❑Yes or &1 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
1f this is a repair,frl!out known well construction ullarmation and explain the nature of the of this record has been provided to the well amier.
repair under f21 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 OW-1 is needed. Indicate TOTAL NUMB$R of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled- f 24.SUBMITTAL INSTRUCTIONS (�
9.Total well depth below land surface: `7� (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 2Q100)
.�d• ft. 24a. For All Wells: Origina l form to Division of Water Resources (DWR),
if Static water level below top of casing: ( ) Information Processing Unit,1'617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: (in) Bit Off: s1972i 24b.For Iniection Wells: Copy to DWR,Undelground Injection Control (IUC)
i, p + Program,1636MSC,Raleigh,INC27699-1636
12.Well construction method: AIR ROTARY 14 .;,
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the r
(io.auger,rotary,cable,direct pusb,eta.) county environmental healt} d' artment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Drodulcing over 100,000 GPD:Copy to DWR,CCPCUA
.� FQ.. ,� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7J� Method of test: tl' D N
13b.Disinfection type: 70%HTH Amount: 9 OZ DATE SITE VISITED: 12-b 'Z 1 �
_ eat