GW1-2022-06605_Well Construction - GW1_20220711

�VEN-T CL-)N 5 TB1,11JCT1,QN RECORD (OW-1) For Internal Use Only:
1.Well Contractor Information:
JCr W '�l✓1S 14.WATERZON15 1
Well Contractor Name FROM TO DESCRRIIPPTION
Ti 1W it-
aL1S.)A �sft rv� ft a4GP►+'+
NC Well Contractor Certification Number Is.OUTER CSNG forQiultiMdRe11sORLIER f a llcable
YADKIN WELL COMPANY,INC. A DITEw
TMCKNE MATERIAL
_ ft, ft. � in.
Company Name Cyt -1�JE U �2 $. 26-is S �l
p. 16.INNER CASING ORT. G Lather dosed-loo )
2.Well Construction Permit#: p �`� FROM TO DLkM1M TSLclairss I%TA7TRTAT.
toList all applicable well construction permits(ae,f1IC,County,State,Variance,eta) •7 O ft G-T in. 'lei?
3.Well Use(checkwell use): ft I ft. in.
17.SCREEN .00
Water Supply Well:
PP y i720Di TO DIAMETER SLOT SUE TSICtaHE5S MATERIAL C`•
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) it-Kesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL, EMPLACEMENT METHOD 6c AMOUNT
Nan-Water Supply Well: O ft. 3 ft. �6I,e ?I Oum l 3
❑Monitoring ❑Recovery it a(. fi• Qv►eJ�( od u y DR
Injection We11: ft 8:
❑Aquifer Recharge ❑Groundwater Remediation
19.5AND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EbIPL.ACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRMLINGLOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmrk typr,gr.du sRq eto.
o ft. ft.
A� �S of
4.Date Wells)Completed: Weuu)#�T�!" ®�'�, qr ft. III ft QC�w J•OGr
52.Well Location: Phone # 4--- 3-x,S/2 11-7 ft {e2 ,ft
rr ft ft
Facility/OwnerName /, FacilityID#(ifapplicable) ft' R %5
2- " {l P-i .L%-CJ ft. ft q V
�•��, z o�'t� �d y /i, � -0c
Physical Address,City,and Zip ft ft. 022
21.REl4IA,RKS
County Parcel Identitioation No.(PIN) a r "9:7 1 •e"s
I hro-'L. ti�l it;s e�Ly JLp}v ++ 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
4, &
6.Is(are)the well(s): C'IPermanent or ❑Temparary Sigua a of ertified Well Contractor Date
By signing thisform,I hereby cert)�that the wall(s)was(were)constructed in accordance with C
7.Is this a repair to an existing well• ❑Yes or 19No 15ANCAC 02C.0100 at-15A NCAC 02C.0200 Nell Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplain the nature ofthe of this record has been provided to the well owner. C
repair=der7021 remarkr section or on the back of thisform.
23.5ite diagram or additionalweII details:
B.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 i needed. Indicate TOTAL NUMBER ofwells (add See Over in Remarlcs Box).'You may also attach additional pages if necessary.
drilled: l� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 g� (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi�erent(example-3Q200'and2©1000 i
24a. For All Wells: Original'form to Division of Water Resources (DWR),
10.Statiewater Ieyt:l below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in.) Bit Off: em• 24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC)
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producil i over 100,000 GPD: Copy to 16-'- CCCP YIA
Permit Progmrn,1611 MSC,Raleigh,
eigh,NC 27699-I611 , n �z~•a
13a.Yield(gpm) �� Method of test: f1�['
70%HTH Z OZ DATE SITE VISITED: �f ll-z
13b.Disinfection type: Amount: L'Cls I^
T)r-i re• i �/,�VISITED BY: C,>01)3,