GW1-2022-03410_Well Construction - GW1_20220315

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,3.Well Contractor lrifor®adort: =°�,��' 3 -
• / ( ��y� f� V��� �' I4.WATEIt2ANE3 r
Well Contractor Name FROM TO DESCnn TION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wellsj OR LINER if a IirBble V
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICiOYESS MATERLIL v
ft ft i 'ln,
Company Name 16.INNER CASING OR TUBING
2.Well Construction Permit#: FROM TO DI Mrrc�
rthermalrlosedm-
Tfficlavrss MATERIAL o�
Lis/all applicable well construction pwmils(i,e f11C,County,State,Yariance,etc.) ft in. v�
3.Well Use(check well use): it ft. in.
Water Supply Well: 17.SCREEN
FROM 70 I AIAMETEA I SLOT SIZE I THICIINESS MATERIAL
❑Agticultural ❑Municipal/lrublic ft. in
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft
❑Iudustrial/Commercial ❑Residential Water Supply(shared) 18-GROUT
❑Irigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTATETHOD&AMOIINT
Non-Water Supply Well:
❑Monitoring ❑Recovery to
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation it
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERUL OD '
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILIMG LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolmgRehnn) ❑0ther(explain under#21Remarks) FROM TO DEscr ON(color.hardnzi,,,os/rorx nsheMe
n ft ft ,C
4.Date Well(s)Completed: 11 Well1D# -
ft ft
5a.Well Location-, Phone # 3rJ 3�„.,kOa fL ft
L.�s�i% �Q�,f�s ft ft.
r
Facility/Owner Name Facility ID#(if applicable) R'! j fL ft
%
Physical Address,City,/and Zip [y,/_ C� ft ft
21.REMARKS
County V Parcel Identi$cationNo.(PIN) ? P'$ ^* n9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(lfwall field,one latllongis sufficient) MAR 16 -
2 tifi 2.Cereatio
D7 . N 791 7
Sr C"�"
6.Is(are)the well(s):�ermanent or ❑Temporary Signature of Certified Well Contractor
By signing thisform,1 hereby certify that the wall(s)was(were)constructed in accordance with
7.Is tbis a repair to an existing well: es or C-.r- G V• 15ANC4C 02C.0100 or 15A NGIC 02C.0200 Well Construction&andards and that a copy
'phis is a repair, ul out!mown well canstructi fnformation and / of the of this record has been provided to the well owner.
npair 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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4a—a ft.
For multiple wells fist all depths IfdOerent(example-3©200'and 2@1001 ( ) Submit this GW-1 within 30 days pf well completion per the following:
n - 24a. For All Wells: Original feria to Division of Water Resources WR)�
10.Static water level below top of casing: [J (ft)
lfwater level Is above casing,use"+" r` e� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: t11 (in.) Bit Off: 5 • �d 24b.For Injection Wells: Copy to'DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well'construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells;Copy to the
._,
(l a sage rotary sable direct push etc.)
county environmental health department of the county where installed
FOR WATER SUPPI Y WELLS ONLY: j
24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
e r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a Y•i d(gpm) Method oftest. !Jki '
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: .. f O—Z .2
VISITED BY:
Form GW-1 North Carolina Department afEnvironmental Quality-Division of Water Resources Revised 6 6-2018