GW1-2022-06640_Well Construction - GW1_20220711

Wi I,j MSTiT�'ZL CTION RECORD(GW-1 or Internal Use Only:
1.Weil ontractor�%nforra:�#ion: � t�
-- A n Fyn 14.WATER ZONES
Well ContrdctorName FROM TO DESCRIPTION
3s'ft. 93 ft.
-303 6 W ft.
NC Well Contractor Certification Number 15.OUTER CASIIYG forIIivlti-cased wells ORLIPIF.R if a livable
YADKIN WELL COMPANY,INC. FROM xo DIAMETER TSICHI'IEss MaTERL&L
ft it in.
Company Name 16.RgNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: Z FROM TO DIAMETM TffiCIQ�MS MATE,
List all appllcable xren construclion permits rL UIC County,State,Variance,eta.) 4—( t ft 1II'
3.Well Use(checkwell use): ft ft.
Water Supply Well: F7.5CREEN
7t011f TO DIAMETER . SLOT SIZE TffiCiQYESS MATERIAL
❑Agricultural �❑ Icipal/Public ft. ft, io•
❑Geothermal(Areating/Cooling Supply) t d sidential Water Supply(single) f,, ft. in.
❑IndustriallCommercial ❑Residential Wafw Supply(shared) H.GROUT
❑lai "on ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-WaterSupplyWell- ft B
❑Monitoring ❑Recovery ft %
Injection Well: M B,
13Aquifer Recharge ❑Groundwater Remediation
19.5ANDIGRAYELPACK ii'a Iicable)
❑Aquifer Storage and Recovery oSalirdy Barrier FROM To MATERIAL EMPLACEMENTMEMOD
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control % ft
❑Geothermal(Closed Loop) ❑Tracer 20.I)MLINGL0G attach additional sheets ifnecacsa
❑Geothermal(HeatinglCooling Retum) 00ther(explain under 1121 Remarks) FROM To DESCRIPTION colon hardness,sclurvtk a in saq do
d.Date Wells)Completed. Well ID# eiCv ft "t. -
t* .M
5a.Well Location: Phone #336- 7: -_267
p ft
F=1 ty/OwacrNsme PacililyID#(if applicable) M ft 4'• 'l� '?N o .
ft. fL JUL 11
Physical Address,City,and .1`t ft ft:
County Paicel fdentificalioallo.(PII3) °'°
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n
S'3�a,/
(ifwoll'field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): permanent or C1Temporary rgnahrre of Certified Well Contractor Date
By signing thisform,I hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an misting well: ❑Yes or Iffiir '0,egpe1,o,' I5A NCAC 02C.0100 or 15A NCAC 01C.0200 Ylell Construction Mandards and that a copy
phis is a repair,fill out Torown well construction!ri formallon and explain the nature o f the ofthis recordhas been provided to the well ownm
repair under$2l remarks section or on the back ofthisform. 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 GW-1 is needed. Indicate TOTAL NL%MBER of wells (add'See Over'in Remarics Box).You may also attach additional pages if necessary.
drilled: �y 1 24.SMM][TT L INSTRUCTIONS
9.Total well depth below land surface: �/3 A) Submit this GW-1 within 30 days of well completion;per the following;
For multiple wells list all depths lfdiferent(example-3Q200'and2@7001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Statlewater level below top of casing: (ft)" (ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
if water level is above casing use"+"
) /' Bit Off' 24b•For lhiectlon Wells: Copy to DWR,Underground Injection Control(IUC) i
11.Borehole diameter: On-) Program,1636 MSC,Raleigh,NC 27699-1636 6
AIR ROTARY s
1Z.Well construction method: 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
PermitProgram,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �t7 Method of test: !`� i+d/'
70°/ HTH !�Z OZ DATE SITE VISITED: e7— 17—`�-Z•
13b.Disinfection type: ° Amount:
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VISITED BY: t t