GW1-2022-06930_Well Construction - GW1_20220603

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�1�T51TFC1U�Il��1q RECORD(GW-D For Internal Use Only:
i
I.Well Contractor Informntion: j
w' _ 1 I
,ti Jecr•, aw I/)5 14.WATER ZONES 1 I -+-
FROM TO Dusc LION
Well Contractor Name ft. 15-0 ft. 1 1 9
a 4 S�A ft. . ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased weIIs ORLINER tf a licabk
YADKIN WELL COMPANY,INC. FROM To DIAMETER THIC[INEss MATERIAL
fit fit. in. -
CompanyName 3 - '7,5'3� �� $'w '^
ul c- 16.INNER CASING OR TUBING:' eothermal rlosed400 )
2.Well Construction Permit#: 33,s0 2.- FROM TO DIAML+TER I THICICMS MATERIAL
List all applicable well construction permits fl.e.WC,County,State,Varlarm;etc.) It
p ft /_ S8 m. � 6 Q 1 V
3.Well Use(checkwell use): ft. (7 fr' v in. (Je,'
Water Supply Well: 19.SCREEN e!
FROM TO pIAMETER SLOT SIZE TSICfOYE55 MATERIAL /'b
❑Agricultural ❑Municipal/Public "';>> ft. ft. :in.
❑Geothermal(Heating/Cooling Supply) 4sidential Water Supply(single) ft. ft. In.
IlIndustriaUCommercial ❑Residential Water Supply(shared) 1S.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft' L ft' Wl- PI-01 Pov reJ (i 6C,5
❑Monitoring ❑Recovery G ft ON? ft QUick 6i V J
Injection Well:
fit. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.5APID/GRAVEL PACK of a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD . ..
❑Aquifer Test ❑StonnwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control fit it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCCR�Tiox color hardaesa,aoiUrock u sae etch.(
&V fr' S0 f ,jJ
4.Date Well(s)Completed: Well1D# '�'
lFt� 2 &a & a11ft.
Sa.Well Location: ft ft. r 91
1/�II Phone #3.�G'-Ci V-2�?'i t �
G
�TLN Q G( ft ft y
Facilitylb4nerName ( f FamayM#(if applicable) fit. ft
�T�L1fL.�`��'i'�'I�L.H •-loefty°(O'/tl� fit ft
Physical Address,City,and Zip fit
21.REMARKS
County Parcel Identification No.(FIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification-
.S 6' Q2 ?3 -1 N J" 3 q'-'- w v
6.Is(are)the well(s): NOPermanent or ❑Temporary Signalirre of qertifled Well Contractor Date S
�,/ By signing thisform,I hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well' ❑Yes or LKo ` - 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction,Standards and that a copy Q
If this is a repair,fill out known wed/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 this farm.
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 `r�I
construction,only 1 GWtl is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. V
drilled: 24.SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface. 'X1.2
For multiple wells list all depths!f different(example-3@200'and 2®1001 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing UrA, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" /
11.Borehole diameter 6 (th) Bit Off: G.0 24b.For Irkiection wells: Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636 ?
AIR ROTARY ;
12.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
E13a.Yield
TER SUPPLY WELLS ONLY: 24d.For Water Wells produ�nk over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gpm) Method oftest: kc70%HTH oZ DATE SITE VISITED: tOnfection type: Amount:
VISITED BY: ' I3