GW1-2022-06933_Well Construction - GW1_20220603

I
t U CONSTRUCTION IRECORD MV-1) For Internal Use Only:
1.6''e!I Contractor Information:
14.WATER ZONE I
Well Contractor Name ]FROM TO I DESCRITION
a45'�A ft. IS ft
f Tr
NC Well Contractor Certification Number 15.01][TER CASING for multi-rased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMLTER THICKNESS MATERIAL
ft. ft. i in.
Company Name ®C✓;6 • 'T,�.3� ('Z $G
16.INNER CASING OR TUBING('eothermal closed-loop)_
2.Well Construction Permit#: 3 7 3(,& FROM I TO DIAMETER I THICKNESS 4AT'ERIAL ('�/
List all applicable well construction permits(Le.UIC,County,State,Martance,etc) l ft. /O ft. in.
VL 3.Well Use(check well use): ft' ft' 1°'
Water Supply Well: 17.SCREEN
a_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMtOUNT
Non-Water Supply Well: 0 ft. 3 ft. V41e O auma 3-fp
❑Monitoring ❑Recovery ft ALI ft' &ttle 6cv; PvyeA 3 wg
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier mom TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardners,sofl/rocktypc,grain sae etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
//�� ft. 160 ft• So+1
4.Date Well(s)Completed: �Z Well m#AAo-?X T I b0 ft' A142 ft G
� n�
5a.Well Location: Phone # 79*- !{02-fi` r.r?T� �f� ft
Sk Gi,iron 94-paa&
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3 S .cowl AQ
Physical Address,City,and Zip v� ft ft a
21.REMAM
County`'.: Parcel Identification No.(PIN) ^r s V
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ` 22.Certification
00 53 � N W °yX au# W
�o�aZ
4-4 CAJ COP
6.Is(are)the we11(s): Ggermanent or ❑Temporary �: Sign a of 4rdfied Well Contractor Date eye A I
�'/l By signing thisform,I hereby cert6 that the well(s)was(were)constructed in accoudmrce with
7.Is this a repair to an existing well: Dyes or 1Plo 15A NCAC 02C.OIgO or 15A NCAC 02C.0200 Well Construction Standards and thai a,,copy XJ
If this is a repair,fill out known well construction Lnformation and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also atffiehadditional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L` 3' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001 1
SO 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
Ifwaier level is above casing,use
11 Borehole diameter: (im) Bit Off: sd f 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinIx over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) _-Method of test: Atr
13b.Disinfection type: 70%n fH Amount: `0 OZ DATE SITE VISITED: 2 7-2 t S f—(�C`•e
Pj a - __ _
VISITED BY: