GW1-2022-03511_Well Construction - GW1_20220316

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t i 1.Well Contractor Int6riontion:
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14.VI'ATEit 20NL+3 {: i
Well Contractor Name FROM TO DESCRIPTION
3�� 6�
NC Well Contractor Certification Number
IS.OUTER CASING formulti-casedwells ORLINF.R ifa livable
YADKIN WELL COMPANY,INC. FROM Ta DIAMETER TH1CiINEss MATERIAL
ft. ffi i in.
Company Name
16.DUSER CASING OR TUBING(ateothe dosed-too
2.Well Construction Permit#: FROM TO DrAMLMR THICTINFSS MATERIAL
List all applicable well construction permits(ae.UIC,County,Slate,parlance,eta) ft it in. v
3.well Use(check well use): ft ft• in. CI
Water Supply Well: 17.SCREEN
FROM TO DIAMK= SLOT SIZE TMCKNESS MATERIAL
❑Agricultural ❑MimicipaVPublic n ;n
❑Geothermal(Heating'Cooling Supply) Residential Water Supply(single) ft it to
❑Industrial/Commercial ❑Residential Water Supply(shared) lg.GROUT
❑Imgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection well: ,..
fL
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK des 'livable
❑Aquifer Storage and Recovery ❑Salinity,Barrier FROM--I TO I MATERIAL xHOD
❑Aquifer Test ❑StDrmwater Drainage ft
[]Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG fattach additional sheets if nececsa
❑Geothermal(Heatmg/CoolmgRetam) ❑Other(explain under#21 REmarks) FROM To DESCRiP1TON cotcr,hardness, -1Vrock in sae,etc -
p ft ft e i
4.Date Well(s)Completed: ot��t �`" well ID# — i 3 / V G
ft ft
5a.WellLocation: Phone # jZ_- 3�„�da
�s� 61"Y�s ft ft
Facility/Owner Name Facility ID#(if applfmbl)' r ft. ft
tY
S a>7 z4e.r i i s^ 4.41 12Q w rt. ft.
Physical Address,City,and Zip ,, `_ ft ft
County Panel IdentidicatiouNo.(PIN) ? R !
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ffwell field,one lat/longis sufficient) 22.Certifieatio
3G !RS"SML' N 81 7 34,3y w G i✓ri
�r rr Ei• .6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor"
By signing thisform,.1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: J 7es or L°J C-�P G V 1 SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction SYm darer and that a copy
If this is a repair,fill out known well conslruc arformation and of the of this record has been provided to the well owner.
repair under#21 remarkr section or an the back ofthis form. 23.Site diagram or additional well details
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells htiving 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: 74.SUBM1TTAL WSTRUCTIONS
9.Total well depth below land surface:` (ft,)
For multiple wells list all depths If different(example-3 c©200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
17P 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ft. Information Processing Unit,1617 MSC,Raleigh,
If water level is above casing use ( ) ggh,NC 27699-1617
11.Borehole diameter: (m). Bit Off: !�• l d 24b.For Injection Wells: Copy to�DWR,Underground Injection Control(1UP
AIR ROTARY
Program,1636 MSC,Raleigh,NC 2I 699-1636 Z
12.Well'ciYnstruction method: 24c.For water Supply and Open-Loop Geothermal Return Well Copy to the //
(ie rotary,cable direct push,etc.) s
vwR. county environmental health department ofthe county where installed
FOR WATER SUPPLY,W" — S ONLY: 24d.For Water Wells producing over 100 000 GPD: Copy to DWR,CCPCUA 34
���' 7 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a:Yield(gpm) Method of test: rt'i%Y' k W
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
VISITED BY:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 B