GW1-2022-08203_Well Construction - GW1_20220513

WELL ICONS TRIUC-110N RECORD(GW-1) For Internal Use Only: !
1.Well Contractor Information:
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Q � �rl V✓ sr')L'/ /1 14.WATER ZONES G
Well Contractor Name FROM TO DESCRIPTION
3 3 6 A a 3r �yd co;
WC Well Cofactor Cettifieaticnxumber 7( ft, / ft .q
I&OUTER CASWG forniulfi-cased wells ORLINER ifs licable) "'
YADKIN WELL COMPANY,ING, FROM xo DIAMETER TffitVE6S MATERIAL .=it r
n
C an = f omp y Name
.�" L 2. rSY' I6.INNER CASIIVG OR TUBING eotHermal dosed-lco ri>,;
2.Well Construction Permit#: FROM TO DIAAG TER Tmcra Ss MATEMAL
List all applicable well construction permirs�4a.UIC,County,Slate,Yarlonce,etc) ft it / in.' g
max/
3.Well Use(check well use): & fr in. ,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMCKMS a' MATERIAL
❑Agricultural ❑Municipai/Public ft. in: j
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) {t Ia; y —S'V
❑Iudustrial/Commercial ` _❑Residential Water Supply(shared)
18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METROD&'AMOUNT1 `r
Non-Water Supply well: ® ft. 3 ft.
❑Monitoring ❑Recover]' R ft-
Injection
Well: a
ft
❑Aquifer Recharge ❑GroundwaterRemediationa�s _r
19.SAND/GRAVEL PACK d a licable s aR
❑Aquifer Storage and Recovery ❑SaliIIity Balder FROM To MATEMAL EMPLACCMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Bxperimental Technology ❑Subsidence Control it sr .yam
❑Geothermal(Closed Loop) DTracer 20.DRILI�VG LOG attach additional sheets if necessa
FROM TO+ DESCRIPTION color hardaes:roVratk s�,etay
❑Geothermal(Heating/CoolingrRRrIu n)
J 3" ❑Other(explain under421 R emaft)
a' wen ID# Q4.Date Well(s Completed.
_r fftt,; ! f �'"�•µ 4 :: r`�k 5a wenLocat1 hY Phone #
' �Gh �NP►1�etS'ttJ l,(„G � ft. ,�''�` f'+" � �.. -� „i. ., .� ' �,
Fenr7ity/OwaerName FaeilityID (ifapplicable) fttt ' r q
Physical Address,City,and
21.REMARKS^ r
Cova Parcel Identification No,(PIN)
Vrmar
5b.Latitude and longitude in degrees/minutes/secoude or decimal degrees: s11
(ifwall field,one lat/longis sufficient) 22.Certification:
'VZ ZZ N V0
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6.Is(are)thewell(s): �ermanent or ❑Temporary ignature of Certified Contractor Date
By signing thisform,I hereby cero that the wells)was ewere)constructed in accordmrce
7.Is this a repair to an existing well: ❑Yes or o ISANCAC 01C.0100 or ISANCAC 02C.0200 Well Construdfon,Strmdards and
If ihEr is are fdl out known well construction Information and explain the nature of the of this record has been provided to the well owner,
repair under#21 remarks section or on the bock of this form. x
23,Site diagram or additional*611 details: xt `
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
construction,only I OW-1 is need Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box),You may also attach add tional pages
drilled L 24.SUBMITT
AL INSTRUCTIONS `� `
9.Total well depth below land surface: �4
For multiple wells list all depths Ifdiffeurnf(ezamp/e-3©200'and 2@100� Submit this GW-1 within 30 daysj of well eompletion per the following f ' l `n
SCE
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form'tD Division of.Water Resources y(DWR),` -i
If water level is above casing,use'"+^ Information Processing Unit,1617 MSC,Raleigh NC 27699-1617 t (([
Bit Off: I F 24b. or Injection Wells:Copy to DWR,Under and Injection �+
11.Borehole diameter: (in.) gro j coon Control(I[JC)
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
(io,anger,rotary,cable,direct push,etc) county environmental health departrnent of the county where installed .
I a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to•DWR,CCPCUA
Permit Program,I611 MSC,Ralei ,NC 27699-I611,
13a.Xield(gpm) Method of test: Q��'
I
13b.Disinfection type, 70%HTH Amount OZ DATE SITE VISITED: e+Z
l/ICITCr1 DV- - �