GW1-2022-03396_Well Construction - GW1_20220315

+CQNk VC 10N RECORD(GW_D For Internal Use Only: i;
1.Well Contractor Information: j
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14.WATER 20NEr, I
Well Contractor Name FROM TO DESCRIPTION
- ft, g, �
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ft
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NC Well Contractor Certification Number I
IS.OUTER CASING for multi-cased Wells)ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TffiQQ1E55 MATERIAL
Company Name in.
16.INNER CASING OR TUBING a eothermal closed-loon)
2.Well Construction Permit#: U e FROM TO DIAs�r.TER THICtamss I MATERIAL
List all applicable well construction permits(ie,r17C,County,State,Variance,et¢J ft P ft G$�� in �)88 6.1
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3.Well Use(check well use): R• ft. In,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft., ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
DIrrigation ❑Wells>100,000 UPI) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply Well: 0 ft. 3 Note Plus
Poureorl e�
❑Monitoring ❑Recovery .R -
Injection Well: 3 �� �'� Groff d A4 ap
❑Aquifer Recharge ❑Groundwater Remediation ft. ft
19.5AND/GRAVEL PACK fa lirable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERIAL, EMPLACEMENTMEPHOD
❑Aquifer Test ❑Stormwater Drainage ft. it.
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DIiILLIlHG LOG attach additional sheets if necessa
❑Geothermal(Heating/CoolingRetOrn) ❑Other(explain under#21 Remailm) mom To DEsexn'Ttox mtcr,tnranes::oiurccx s sru em
d ft 7? ft.
4.Date Well(s)Completed: �q Well ID# S70 fL
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Sa.Well Location- Phone#
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0 CIA !J a ft ft �
�eN _ � tea r�-'e 4'<���'� ���
Facility/Owns Name Facility ID#(if appIioable) ft ft > " ./ _
Pous Lob ft AR 1
Physical Address,Gusty-,and Zip � �9 ry ®_5L ft ft
21
t�/ e r f7��ca7� REMARKS
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Cormty P=4Idcatification No.(PIPI) Votel ✓� t ,�'`+4r 4 t '�O VA `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Tki t n k 4 15 4*IS"-y b'
(ifwell field,one lat(longis sufficient) 22.Certification
Nam! f wl<r/s W
6.Is(are)the well(s):Xermanent or ❑Temporary Sign of`C#6fied Well Contractor Dam
� By signing thisform,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fiq ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction SYandardls 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 pravided to the well owner.
repair under#2I 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 i OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over`in Remarks Box).You may also attach additional pages if necessarq. •;'_,.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S-10 ft.
For multiple wells list all depths lfdiiferent(example-3@2 00'and 2@1001 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: g ft 24a. For All Wells: Original farm to Division of Water Resources (DWR)
Ifwater level is above casing,use"+" ( ) Information Processing Unit;1617 MSC,Raleigh,NC 27699-16I7
Bit Off: �• 24b.For Infection Wells: Co to D
11.Borehole diameter: (in.) Copy WR,Underground Injection Control
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY �.
24c.For Water Supply and Open-Loop Geothermal Return Wells Copp to the.'r"
(i e.auger,rotary,cable,direct push etc) county environmental health department of the county whore installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA ,
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13a.Yield(gpm) NA Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: Q` I
70%HTH /yh OZ DATE SITE V15I 'ED::'
13b.Disinfection type: Amount: Bpj
VISITED BY: 1r8r. +p0►