GW1-2022-06643_Well Construction - GW1_20220711

'L" CG�I�T�TJT�'1U 11T 1I'ON RZOOR D CGW-11 F,or Internal Use Only:
1,Well Contractor Information:
` C ma6 / 14.WATER ZONES
FROM TO DESCR1PTiON
Well Contractor ame 39 eft.
/J 5 D'f7 ft. ft
NC Well Contractor CettiScafionNumber is.OUTER CASING-for nivlti-cased wells ORL NER if a linable
YADKIN WELL COMPANY,INC. FROM ft. To #t DIA TffiCENE s MATERIAL
in. r
Company Name 16.RgNER CASING OR TUBING, eethermal closed-loo .�
FROM TO Dry ^gin THICKNESS MATERIAL
2.Well Construction Permit#: {£
Llst all applicable well constructionpeMYS CLUL II1C,County,State,Variance,etc.)
ft
3.Well Use(check well use):
I7.S CREEL N �..�
Water Supply Well: MOM TO DLil41LrER ZLOTS l;E CtixESS 34ATERIAL
❑Agricultural C1M/unicipal/Public it. ft. a. "
❑Geothermal(HeatinglCooling Supply) Residential Water Supply(single)
ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ; '18.GROUT
❑Wells>100,000 GPD F EN
ROM TO , MATMAI. ZMLACEMTMETHOD&AMOUNT
❑Iuigation 0 {t; r
Non-Water Supply Well: d
❑Monitoring Recovery - Ste' ft �� ft >1-5-lor
Injection Well; f
❑Aquifer Recharge ❑GrmmdwaterRemediation 19 SAND/GRAVEL PACK da licable)
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM To MATenrer. Eltffr:ACEMENTrd=OD
❑Aquifer Test [7Stormwater Drainage '
❑Bxperimmtal Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 2a.DRIi,LING;LOG aHaclr additional cheats or,harsse
FBOM TO DESCRCaZTPTION color,harda'ss.s°Vmrlc "a s'vr,ctc
❑Geothermal(Heating/Cooling ❑Other(explain under#21 Remarks) �, ®.
4.Date Wells)Completed: Well IN e- Q �' v ft." ''�-� `�
m ` � -71
��� � �
5a.Well Location: P hone # .-(3 ',--71'q I�� ��� ft r fL
FamlitylownerName FacilityID#(if applicable)
_ ft. �.
- ft. ff• F u. - a S 3 T N �J
Physical A.dd=s,City.and 73P
l✓ `, � 21.REMARI€S _
County parcel IdentficationNo.
,
5b.Latitude and longitude in degrees/minuites/seconds or decimal degrees: '.,t_�Ws,w
(ifwdl field,one lat/loagis sufficient) 22."Certification;
Nis 5762� W P �ssa2..
8i a of C ed We Cw=tor Date
6.Is(are)the well(s): SWermanent or ❑Temporary -�
014
By signing thisfa m,I hereby certjfythat the wells)was(were)constructed In arrnrdm&.with G
15ANCAC 02C.0100 or 15ANCAC 02C.0200 Nell Construction Standards mitl'ihat
7.Is this a repair to as existing well: Dyes or ?ro of this record has been provided to the well owner. C
If this is a repair,fdl out(mown well construction information and uplain the nature pf the C
repair under#2l remarks section or on the backofthisform. 23.Site diagram or addilionalw,ell,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 (add'See Ovet'in Remark Box).You may also attach additional pages if necessary•
construction,only 1 1-1 is needed. Indicate TOTAL NUMBER of wells
wed. 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface:, ` �9 (f') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths IfdI erent(example-3(n)200'and 2@1001
24a. Far All Wells: original dorm to Division :of Water Resources,(DWR),
10.Statiewater IevE below top of casing: '70 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
`Jfi"er level Is above casing,use
r Bit Off: 10-6W 24b.For Injection Wells: Copy to DWR,Underground Injection Control PC)
Borehole diameter: (in.) 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.augc,rotary,oable,directpusk atc) county emimnmental health department of the county where installed
Li3b.
ATER SUPPLY WELLS ONLY' 24d.'For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
v /7� P.ennit Prpgram,1611 MSC,Raleigh,NC 27699-1611
eld(gpm)_ Method of test: 'C
70%HTH Amount. �� OZ DATE SITE VISITED:
sinfection type: - ,� 1"
Y7151TED BY: