GW1-2022-08231_Well Construction - GW1_20220513

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` L,ICONS TWXTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
e
3et1;y WoL*t nS 14.WATER ZONES l (O
Well Contractor Name FROr2 TO DESCRIPTION
a 4 5a� ft. y0 ft 44,e,
ft. ft {
NC Well Contractor Certification Number 15,OUTER CASING for multi-caied;wells ORLWER of a livable
YADKIN WELL COMPANY,INC. FROM To DL4Iv=R THIt�a4Ess ivIATERIAI
ft ft. in.
Company Name
16.1NNER CASING OR TUBING( ecthermal dosed-loon)
2.Well Construction Permit#: l'J "" FROM TO DIAMETER I THIClaiM- S I MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc) ft CC) ft G �8 in• 5O M I PVC_
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3.Well Use(check well use): ft. ft.
1D'
Water Supply Well: 17.5CREEN
FROM TO DIAMETER SLOT SIZE THICIMSS MATTutar.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation []Wells>100,000 GPD FROM I TO MATERAAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft• $ ft. Nod PI Q WCVJ �-
❑Monitoring ❑Recovery S ft ft v n
Injection Well: ft. I ft. ` rV Q'S�
❑Aquifer Recharge ❑Groundwater Remediation
❑ Ifer Storage find Recovery ❑$ Barrier 19•SAND/GRAVEL PACK rf a livable
Aqu rage �' �Y FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa C
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remad6) FROM To DESCRIPYTON rotor,hardness,soittrntktypt,grran sae,ete
0 ft ft. ®�•�
4.Date Well(s)Completed: •� a7. Well im "7 J. IS ft .120t
ft ft
! Phone # $� �- '
5a.Well Location: � �..�03
6 o&V A A e A / it it C
Facility/Own amc Facility M#(if applicable) ft ft.
®� �ehnv�a�'sdQ ft. ft
Physical Address,
Address,City,and Zif ft ft
W I t1Cef - 21.REMARKS
County Parcel Identification No.CMD
5b.Latitude and longitude in degrees/minutes/seconds ordecimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification'
l S 39l r N S1 �6. 7 f 8'� W S I k*
6.Is(are)the well(s): ermanent or ❑Temporary Sigaata4 of C ed Well Cofactor'; Data
By signing thisfarm,I hereby ceritfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an elasting well: ❑Yes or A0 15ANC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction SYandards and that a copy -�
l this is a repair,fill out known well construction information and erplain the nature of the of this record has been provided to the well owner. S
repair under*21 remarkr 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 1 GW-j is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. d
drilled: ` 24.SUBIVIITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 a70 (ft) Submit this GW-1 within 30 dayk of well completion per the following:
For multiple wells list all depths Ifdrfferent(example-3Q200'and 2®100D
3b'0 ' (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static l Is above
levtl below top of casing: Information Processing Unit,16171 MSC,Raleigh,NC 27699-1617
lfwater level is above casing use"+' I
11.Borehole diameter: (in.) Bit Off: .0`6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Prograrn,1636 MSC,Raleigh,NC 27699-1636
12.Welleonstruction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the ,
(i.e.auger,rotary,cable,direct push,etc.) county environmental health deparhnent of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin I over 100,000 GPD:Copy to DWI?,CCPCUA
Pemrit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 9 Method of test: g'L l✓
13b.Disinfection type: 70%HTH Amount: 17 OZ DATE SITE VISITED: ,^g''� G" 12 t
VISITED BY: