GW1-2022-06608_Well Construction - GW1_20220711

&STRUCTION REO-ORD(G For Internal Use Only:
1.Well Contractor Infformstion:
14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION _
A`'{D A g`31t. 1'J ft• 1 S Cs&A
p ft. it
NC Well Contractor CettificationNumber IS.OUTER CASING for niulfi-ra�d s ORLINER if a linable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THIC[flVEss MATERIAL
ft ft. in.
Company Name
16.IlVNE$CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM To I DIAA TER I =cre4Ess ATATERIAL A
List all applicable well construction pwunits(t a UIC,County,Slate,�ariance,eta) It /D 7 ft to VC/ In s p R 21, F V G
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE TMCIMss MATERIAL
�AgriculturaI ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/CooIing Supply) [residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ®❑Residential Water Supply(shared) IB.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATEMAL EMPLACEMENT ATETHOD&AMOUNT
Non-Water Supply Well: 8 ft, Z- R ®fie P� Pourer
❑Monitoring ❑Recovery Af ft ,p ft xA6ra;6 PV ,� 64
Injection Well: f.
fL❑Aquifer Recharge ❑Groundwater Remediation
19.SAPID/GRAVEL PACK rf a linable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEMAL. EMLACEMENT METHoD
❑Aquifer Test ❑StorrawaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRIILTNGLOG fattach additional sheets ifnecessa��)
❑Geothermal(Heating/Cooling Return) El Other(explain under 921 Remarks) FROM TO DESCRTP71ox color,hardness,saiVrnrktypr,gr.tim sae,cte-
�/i ft t
`l f O i
4.Date Wells)Completed:4, I7l12 WellEv 5'� 1 -7 ft- 922 ft 6-land,
�
ft ft
Sa.w ocation: Phone # �� -4�'
,� re'4 ty��-I ft ft
Facility/,Owwn{,erName �/ Facility lD#(if applicable) ft ft f y
ft. #t a ,�• .V{�
Physical Address,City,aad�Zi/p� ft ft J U l I,7
1//� �K 21.RRMAWO
County Parcel Identification No.(PIA!) IM2 _
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/longis sufficient) 22.Certification:
;;�• Zl q N $ 1 3� /15q W '4' G I1y l�2
6.Is(are)the well(s): K ermanent or ❑Temporary Signature of Cftified Viell Contractor Date -4.
By signing thisform,Ih ere bycerhfythat thawa11(s)was(were)canstructedin accordance with
7.Is this a repair to an existing well: ❑Yes or AID 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Fell Construction Standards and that a copy
If this is a repair,fdl out!mown well construction information and explain the nature of the of this record has beenprovided to the well owner.
repair under#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
construction,only I OW-)
W 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:_ ��� (ft) we Submit this GW-1 within 30 days of well completion per the followin
For multiple wells list all depths!f different(example-3(a)200'and 2Q1001 S' P P g:
St0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
"10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 °
lfwater level is above casing use"+"
Bit p{f; �t �v� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�) 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
(Lo.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 10D,000 GPD: Copy to DWR,CCPCUA
/F,'- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 70 Method of test: �p
13b.Disinfection type: 70%HTH Amount: O OZ DATE SITE VISITED:
Uri r•a r
VISITED BY: I/A