GW1-2022-03391_Well Construction - GW1_20220315

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�QNSTR UCTIQN RECORD(G'VV-11 For Internal Use Only:
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1.Well Contractor Information:
19.WATER ZONES
Well Contractor Name FROM TO DLSCRTPTION
3s�� ft 3
r,', q
' 4 s ft 7
-30 3 �
NC Well Contractor Certification `17I '' 3'73 ft 3 � r
15.OUTER CASING for multi-rased wens ORLrgm if a ticable
YADKIN WELL COMPANY,INC. FROM To D R THICIINESS MATRRTdr• .�+
ft1 , in. \
Company Name A.'P3C-�7TJ-�i4If A'
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16.U04ER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: % `2-�4 FROM TO I DMAMMR I TE1C1=Ss MATERIAL
List all applicable well construction permits(r e.WC,County,State,Variance,eta) ft Lis ft 6 t�t� 'n• S�A� , y Vv
3.Well Use(checkwell use): ft ft. in.
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Water Supply Well: 17.SCREEN
MOM TO DIAMETER SLOT SIZE THICIO aSs MATERLIL
❑Agricultural ❑ icipal/Public ft, is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
ElIrrigation ❑Wells>100,000 GPD PROM TO MATERML EMPLACEMENT AMTHOD&AMOUNT
Non--Water Supply Well: U ft. 3 3!4
❑Monitoring ❑Recovery 3 ft � ft. c�� SiOt` L1I�L
Injection Well: ni /
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAPID/GRAVEL PACK of a Ucable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO TERIAL E-WIPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DAILLINGLOG attach additional sheets if necevsa
❑Geothermal(Heating/Cooling Retmn) ❑Other(explain under#21 Remarics) FROM TO DESCRIPTrox color,b&dness,:ml/roc& a aia size,etc
+i ft. $ ft S f
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4.Date Wells)Completed:,;?
-I 1-Z 7, Well ID# A* NO 3$ ft' 3 i0 it (�' rw,44
5a Well Location: P�10110 # 79,S (�fi>L�,�(� 3 f ft �ZZ So
Facility/OwnerNamfe Facility ID#(ifapplicable) ft ft.
(6'q &y--TF .i ce[/t c.+2. NC ft ft P
Physical Address,City,and Zip e27CO ft rt MAR 1 6 2022
au f 21.REMARKS Q
County Parcel Identification No.(PIbI)
4RS`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(ifwell field,one lat/long is.sufficient) 22.Certification:
6.Is(are)the well(s): HPermanent or ❑Temporary rgnature of Certified Well Contractor Date
By signing thisfarm,]hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LR1Vo ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fd/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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarks Box).You may also attach additional pages ff necessary.
drilled: 01 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/f different(example-30a 200'and 2Q1001
10.Static water levkI below top of casing: IrQ (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level Is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Bit Off: ° 31 24b.For Injection'Wells:,Cop
y1.Borehole diameter: (�o (in.) y to.DWR,Underground Injection Control(IUC) 1*4
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
(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 roducin over 100,000 GPD: Copy to DWR,CCPCUA
' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) f 0 Method of test: rl
13b.Disinfection type: 70%HTH Amount: .?1 Y OZ DATE SITE VISITED:
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