GW1-2022-06609_Well Construction - GW1_20220711

For Internal Use Only: I
1,Well Contractor Inforn:rtion:
it L
14.1'VATER ZONES I ��
FROM TO DESCRIPTION
Well Contractor'Name �'�ft. � �•
►1 �'�.��J'Q C� ft. � ft
NC Well Contractor CettiScationNumber t/ 15,OUTER CASING foruiniti-cased wells ORLINER if a licable
YADKIN WELL COMPANY,INC. I n j�f 1 FROM To DUMICTER THICKNESS MATERrnt
a/V Fl ft. ft. in.
Company Name
I6•RIUIM CASING OR TUBING(geothermal closed-loo
Z.VYellConstr-uctionPermit#: � � i" t�. FROM TO DIAMETER THICIINESS ATATMWLL
List all applicable well construcilon permits i a.U1C,County,State,Variance,etc_ ft. �Dy in" bl ke-c
3.Well Use(check well use): ft• ft. mf (�in.
17.SCREEN
Water Supply Well:
IR0111 TO DIAMETL'R SLOT SIZE THIC104ES5 MATERIAL
❑Agricultural ❑MunicipaI/Public ft. ff. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single:) ft ft.
❑Industrial/Commercial ❑Residertial Water Supply(shared) 18.GROUT
❑Irrigation '❑Wells>100,000 GPD FROM I To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 4 �` s /u e Q.�
❑Monitoring DRecovery
Injection Well: °
ft ft.
❑Aquifer Recharge []Groundwater Remetiiation
19.SAND/GRAVEL PACK Ha Ucable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
PAgriifer Test, oStormwater Drainage
❑Experimental Terhnology ❑Subsidence Control ft it p
❑Geothermal(CIosedLoop) ❑Tracer' 20•DRILL7NGLOG attack additional sheets ifnecessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soillrec& e, sae,ct�
A�, ft.
4.Date Weil(s)Completed; !Well 1D#l ft 1:L ft" ' •r®s,
5a.Well Location: Phoneft. IL yvi
# a' 0.�6 I� ��- •���
Face /OwnerN Facility (if applicable) Y
7ity C �p ) fl ft ft ems.a e c%'n t`r�
ft. ft
Physical Addmss,•City,and Z.
21-REMARI{S
a
county Parcel Identification No.(PIN) r; :
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell feld,'one lat/longis sufficient) rT�LJ� f 22.Certification:
4. 6 3 �l!f N iSl Wfl� J,� u 3'�
---rr , x. e C b.,J gf,
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Cdntrector e, s Date '
e /rrt tdexplafn
By signing thisfarm,Ihereby certifythat the well(;)was(were)constructedinaccordancewith
7.Is this a repair to an existing well: ❑Yes or 15A NCRC 01C.0100 or 15A NCAC 02CX.200'1Pell Construction Sta dards and thata copy1f this is,arepair,fdloutlmown well construction information the nature of the ofthis record has been provided to the well owner.
repair under 121 reinarki'section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells (add See Over'in Remarla Box).You may also attach additional pages if necessary.
drilled: ' , 24.SUBNEC TAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths lfdiferenf(eromple-3 r©200'and 2®100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievtl below top of casing: J V (ft-) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,vse"+" � �
'11.Borehole diameter (in) 13it Off, 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IU&)
.;' 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,miary,cable,direct push,etc.) county environmental health deplartment of the county where installed
jt FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingloyer 100,000 GPD: Copy to DWR,CCPCUA
6 44. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: � 7'?
V 70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Ji / —�
/ Amount �A 5'.1 d
I vg T I VISITED BY:
Fo -th CarolinaDepartrnent of Environmental Quality-Division of Water Resources Revised 6-6-2018