GW1-2022-03409_Well Construction - GW1_20220315

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• L,L CONSTRUCTION 11ECORIP fGW-1� For Internal Use Only:
F
I.Well Contractor Infornntion:
14.WATER ZONES
Well Can cror MiA
Name - FROM TO DESCRIPTION
--�--L-!! ftG ft. ©ft. SO] I ar < e iou
, ft
NC Well Contractor Certification Numbs
15.OUTER CASING formulfi-casedrieDs ORLIf1ER rfa lirabk
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATEMAL
ft. ft. in.
CompaayName 72 16.INNER CASING OR TUBING fewthermaldosed-loo
2.well Construction Permit#: 331 p Y- ®1 FROM TO DIAMETER TMCKNE.Ss I AUTERIAAL LE
List all applicable well construction permits rEm UIC,County,State,Yarfance,etc) ft ra' SIVVL
i
3.Well Use(check well use): ' 1n-
17.SCREEN
Water Supply Well-
FROM TO DIAMETER SLOT SIZE THIClaasS MATERUL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) >6esidential Water Supply(single) ft. ft.
❑Industrial/Commercial' ❑Residential Water Supply(shared) 18.GROUT
=„ FROM A2 To MATERIAL EMPLACEMENT ETHOD&AMOUNT
❑Irrigation ❑Wells>100,000 GPD .`
Non-Water Supply Well: ft' S !t
❑Monitoring ❑Recovery S ft ft. Fy^ ,4 f fw .
In)ecdou,Well:
ft. %
❑Aquifer Recharge ❑Groundwater Remediation
19.OAquifer Storage and Recovery ❑Salinity Barrier SAND/GI'SAND/GRAVEL PACK MATES applicable)
EMMPLAC MENTMETHOD
[]Aquifer Test ❑Stormwater Drainage fL ft-
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal.(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geotherral(Heating/Cooiing Rotmn). ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION rotor,hardnen,soil/rack
/ a nra sas etc
tef
ft. S ^ c- SWellID# Slf it
Te -
5s Well Location ftPhbne#3,36-3a� -/a �� r►cvP �� �a� ..fL +
for 1
F 'ty/Owner Name Facility
/ID#(rf applicable) L' ft.- Li 2 R .f pP- p(- 4i
® �
Physical Address City and lap fi bT �� fL ft �._... a T
7.1.REMARKS
-.
cpu*' - � Parcel Identification No.(FIlJ) M.� pp�
5b.Latitft&and longitude in degrees/minutes/seconda or decimal degrees: nlil 1
(ifvt llu 14;onC laUlongis sa cieat) 22.Certification •{ i`c 1.. :�,s r.' '.�
6.Is(are)the well(s): ll?Permanent or ❑Temporary Signature of Certified Well Contractor Date a,
By signing thisform,l hereby certify that the wells)was(were)constructed in accon*mce wrrh}: r
7.Is this a repair to an existing well: ❑Yes or 96o 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fdl out known well construction information and explain the nature of the of this record nos been provided/o the well owner
repair render f21 remarks seciton 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 mfo
construction,only 1 GW=I is needed Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: �' 24.SUBMITTAL INSTRUCTIONS
u,.
9.Total well depth below land surface: 61P (ft) Submit this GW-1 within 30 days of well completion per,the following:
For multiple wells list all depths ff different(e ample-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ®� (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
Ifwater level Is above casing,use 1
Il.Borehole diameter (in.) Bit Off: �r / � 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NG 27699-1636
AIR ROTARY I ,
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. 6
FOR WATER SUPPLY WELTS ONLY: 24d For.Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA SU
' Permrt Program,1611 MSC,Ra]eigh,NC 27699-I611
13a.Yield(gpm) Method of test:, IU
13b.Disinfection type: 70%HTH Amount ,OZ DgTE SITE VISITED: �'G... (-2(
,
Uri r•a• - P S +sk �ti,t L rv[517ED BY], .� '.