GW1-2022-08493_Well Construction - GW1_20220513

WELL CONS I IUC iTION RECORD(GH-1) For Internal Use Only:
1.Well Contractor Information:
L
lA.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
�4S�A ft. �SO GPM
/93 ?31 GPnn �b
NC Well Contractor Certification Numbs
15,OUTER CASING for multi-rased Wells)ORLWER rf a lieable
YADKIN WELL COMPANY,INC. FROM To DIAMEM TBICaNEss MATERIAL
ft. ft. in.
Company Name 16.DWER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: a"Sr�✓ 1B FROM TO Dr•MErTFR I THICKNESS NIATMIAL
List all applicable well construction permits ri e,E=County,State,Variance,eta) ft lot ft G 1% in. 15PR:)l
3.Well Use(check well use): ft' it' in.
Water Supply Well: 17.SCREEN
pP y FRont TO DIAMETER SLOT SIZE TEaci MESS MATERIAL
❑Agricultural ❑Municipal/Public`
❑Geothermal(Heating/Cooling Supply) P&sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
✓ Non-Water Supply Well: 0 ft' 3ft' 144e Miq
you re e( 3 biz
❑Monitoring ❑Recovery it e�e7 ft• G�wcC tiCi ft✓
injection Well: ft ft
•❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVES.PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERAL E11�LACLaMNTML'THOn
❑Aquifer Test • ❑Stormwater Drainage it.
❑Experimental Technology _ ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIlVG LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilirock a grain size,ctc
93 ft.
4.Date Well(s)Completed:. 3 eu Wellm# t%' ft' -712.
5a.WellLocation: Phone # L 4`T yaA -1 C
Facility/OwnerName : Facility M#Cif applicamr) ft. fRECEINIr
Physical Addrrss,City.and Zip ft ft.
21.REMARKS C
County LY t�C Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3T S r Z 44K N YO T1 3,y. G Z W r S13 I.P.3 U
ermanent or ❑Temporary Sign 'of Ce ed Well Contractor Date
6.Is(are)the weIl(s): P
By signing thisfarm,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ICQo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information add explain the nature of the of this record has been provided to the well owner.
repair under#21 remarla section or an the back of this form.
23.Site diagram or additionalvrell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of Us page to provide additional well construction info
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarla Box) You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3(n)200'and 2@1001
!/V (ft) 242. 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
Ifwater level is above casing,use
y 11.Borehole diameter: t'o (in•) Bit Off: to•O).T 24b.For Injection 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producintr:over 100,000 GPD: Copy to DWR,CCPCUA
e- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: IV
IV
13b.Disinfection type: 70%HTH Amount: / OZ DATE SITE VISITED:
Pri rtP_e I _ .__�td sl E BY: