GW1-2022-06383_Well Construction - GW1_20220603

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WELL CONS:!& UCTION RECORD (GW-1) For Internal Use Only: j
I.Well Contractor lnforruntion:
46 t,,//l 14.WATER ZONES :
Well Contractor Name
FROM I TO DESCRIPTION CIS
3d 36 ,A � e�s� �
ft ' -
NC Well Contractor Certification Number
15.OUTER CASING forniulti-cesedwells ORLINER rfa lirs+ble
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCFOVEss MATERIAL
iin
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
2.Well COnsh action Permit#: o!l el I T- ;0 2)t FROM TO DIAMETER THIcHNmi s TfATERIAI
List all applicable well construction pennfis(Le.EX,County,Slate,Variance,eta) ft ft in.
3.Well Use(check well use): 1 ft 10 3 ft' �rj r 61 0 64 It" SIU,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TEICIINESS MATERIAL-
❑Agricultural ❑Municipavpablic !t. ft. t in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
ft.
❑Industrial/CommercialResidential Water Supply(shared) 18.GROUT
❑Irrigation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft 3 ft 1j,., 0,.a C G
❑Monitoring ❑Recovery it ft
Injection Well: ft. ft
[]Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK sfa I'licable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. j
❑Experimental Technology ❑Subsidence Control ft. jf
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG Mach ad oaal sheets if necessa �J
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarics) FROM To DESCfdMON color,hardness,sail/ruck typr,grain she,etc
ft. � fL of
4.Date Well(s)Completed:S-/7- Z Z Well m# t�0-/ 3Z) 7- ft 2- 0 t
Sa.AWell Loocation:/J / Phone #73!C 3 o t /20 fL 176 f 49
p �1
A�1 d
Facility/�OwwnerName Facility D#(if applicable) ft. ft
ty
{ ( O I a5/tom" a e ft. ft
Physical Address,City,and Zip ft. ft
REMARKS ry` *.,':.;F' r1,t ,.t,
Co Parcel Idmecation No.(PIN) /Z f A,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /T*0_yt0 Ar-v-lark' .2000 a AV
(ifwellfield,one laUloagis sufficient) 22.Certification:
3 9 14,V N Y,4 `110 331SS W
6.Is(are)the well(s):*ermanent or ❑Temporary Signature of Certified Well Contractor^' Date
By signing thisform,1 hereby cer@�that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well• ❑Yes or dlo 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Mown we11 construction information and explain the nature of the of this record has been provided to the'well owner.
repair render#21 remarks section or on the back of thisform. 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 p
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Rema&Box).You may also attach additional pages if necessary. 7—
drilled: L
^1 24.SUBMITTAL INSTRUCTIONS Q
9.Total well depth below land surface: Ll - (ft.)
For mu ells fist all depths If different(eramp/e-3(n)200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
-f water level is above casing,use
11.Borehole diameter (�) Bit Off: '.� 9 7 1 24b.For Ialection Wells: Copy to DWR,Underground Injection Control(IUC)
Prograrr4 1636 MSC,Raleigb,NC127699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(La.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing;over 100,000 GPD: Copy to DWR,CCPCUA
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: G V q I
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
psi c•�_ J IS T BY: y `✓