GW1-2022-03514_Well Construction - GW1_20220316

RTMItQNS I^�1�TC CTION RECORD (GNV-1) For Internal Use Only:
1.Wet?Contractor Information:
�� �� y I 1 . 14.WATER ZONES \
//�� FROM TO DE5 TION
Well Contractor N me
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING foraiulfi-casedweDs ORLTIIER da livable
YADKIN WELL COMPANY,ING. FROM TO DIAMSr'R TBIC871ES5 MATERIAL
ft, ft in.
CompanyName)@,f ,,, p,it g/A � „� (� `�"-ys 2-1 16.INNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: ! FROM TO DUAL-- R I TMCIMTSS MATERIAL
List all applicable well construction permifs(te.UIC,County,Slate,Variance,etc) �• fti ft Jan' SJ)9Z�4 UC,
3.Well Use(checkwell use): ft ft. in.
Water Supply Well: 17.SCREEN
PP Y Fltoluf TO DLkh1L-= SLOT SIZE THICKNESS MATERLIL
❑Agricultural ❑NfticipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1314sidential Water Supply(single) ft, ft. in,
❑IndustriaVCommercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMI NT METHOD&AMOUNT
Non-Water Supply Well: O ft. < \ ft. i3-F►1 'G�l: c�vrA.A(
❑Monitoring ❑Recovery q ft t1t! ' ft f
d-7 cr- vrc U
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test liStormwater Drainage ft ft
❑Experimental Technology []Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Ret im) ❑Other( lain tinder#21 Remarks) FROM TO DESCRIPTION mlaq hardness,saVrork grain sae etc
D ft. g' ft•
4.DateWell(s)Completed: `91-- WeIIII) �> _ ft' 31410 IL yYI4l/
5a.Well Location: «, ft if
Phone #��� r��• �J"7
�ey�s R� �' ' ft ft
_z ft ft
Fa//ctlity/Owner�,Ngame /p, FacilityID#(if ajpplic�able)
tic),� / ® '0'r- ToN1t'.1 6J/I� ��GI R fL
Physical Adams,City,and Zip
ft if. l f y
ash I 2L RF.MARICS Mpg
County Parcel Identification No.(MD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
)("dwell field,one lat/lon is sufficient) 22.Certification:
cation:
A.- i'3' I C N Ta+� J JOLT W
6.Is(are)the well(s): Wermanent or ❑Temporary Sipgrare of&fified Well Contractor Date
By signingthisform,I hereby certify that the well(s)was(were)constructed in accordmrce with
L�io
7.Is this a repair to an eldsting well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction,Stin7dards and that a copy
If this is a repalr, 1111 out known well construction information and explain the nature of the of this recordhas beenprovided 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 10 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarla Box).You may also attach additional pages if necessary.
drilled: (, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 7 Q, (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdlfferenl(example-3@200'and 2@1000
( 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: l (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" ``
11.Borehole diameter: (p (in) Bit Off: •G vO 24b.For Injection Wells: Copy,to DWR,Underground Injection Control(TUC)
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
(i.e.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinle over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /
u 5 Method of test: -/ , 11G.r Permit Program,1611 MSC,Raleigh,NC 27699-I611
T _ v
70%HTH OZ DATE SITE VISITED: fl-.r'-71
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13b.Disinfection type: Amount: � �
Uri ra- VISITED BY: '.se:d