GW1-2022-08512_Well Construction - GW1_20220513

ems iIIku bTibN REcoRD(Gw-1�g,�-1;✓ ) For Internal Use Only: f
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1.Well Contractor In-rornation:
-� 11
l� 1 14.WATER ZONES
FROM j TO DESCRIPTION
Well ContrraactorN me S�'8ft �6o ft �O
r7 5-7 1 A
NC Well Contactor CertificationNumbw 15.OUTER CASING for multi-cased vveDs ORLINFA if a livable
YADKIN WELL COMPANY,INC. FROM To nIAMETER Tuass MATERIAL
ft. I ft. I in.
Company Name Yd 1 X i r, 7 Z♦- S[q "2 qO zr 16.INNER CASING OR TUBING eothermal dosed loo )
2.WeU Construction PPermit#: 013 S �o2Z 11172.ESCREEN
TO DIAarMR TEICIINE55 MATERIAL
Lis/all applicable well construction permits(i.e.U1C,County,State,Variance,etc) ft ,ln' -a[ p(�G
3.Well Use(checkwell use): ft' in.
Water Supply Well: F7ton To DIAMETER SLOT SIZE THICIINE55 MATERIAL
OAgricultural ❑MunicipaVPublic ft.
❑Geothermal(Heating/Cooling Supply) 4sidential Water Supply(single) ft. ft. in.
[Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft, ft' ° u✓
OMonitoring ❑Recovery tj ft �p ft J�v d Cad
Injection Well: ft ft
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL. EMPI.ACEMENTMETHOD
OAquifer Test ❑Starmwater Drainage ft ft =e
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLTNGLOG attach additional sheets ifneCE352ryl
❑Geothermal(Heating/CoolingRet=) ❑Other(explain under921 Reimarks) FROM TO DESCRIPTION color,hardness,soiUrnek grain sae,etc.
D ft. 7 ft. o.Z
4.Date Well(s)Completed: -B-�Z WeH1[D#A P QQ-? 71 ft yso fL /2rlfo/ _ o/b Cr7'an.• 0
5a.WellLocatiori:' Phone # �- 7�3.:�
y5 Of 5;-0• �r lja oA Aos tit-I.-Io
�G,,�• r �- S7a ft. s�o r IL rttW ate•4e
Faccility/Own Name ii Facility MA(if applicable) ft.ft.
3.33-7
f�� / n
61
Physical Address,City,and Zip fL ft.
f CA k( 0/1 21.REDAARTCA
MAY I
CoV* Parcel Identification No.(PIN)
Inforsnalit3n Prt>ctg Urdl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t DWQMGG
(ifwall field,one lat/longis sufficient) 22.Certification: ,,��
ID e Z h N g s w G�iLw 1��z
6.Is(are)the well(s): WFermanent or ❑Temporary Sig4ife of Cerf6ed Well Contractor Elatr
By signing thisfonn,l hereby certify that the well(s)was(were)constructed in accordance with
existing 7.Is this a repair to an sting well: Dyes or' �0 1SANCAC 02C.0100 or 15ANC4C'02C.0200 Well Construction Standards and that a copy C
ythis is a repair,fill out(mown well const ruction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks sectfon or on the back of this form. 23.Site diagram or additional well details: C
S.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 101-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarla Box).,You may also attach additional pages if necessary.
drilled:, r �• 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J g�• (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Ifst all depths If dffemi(eramp/e-3 c©200-and 2@100�
(ft)�d• 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
Ifwater level/s above casing,use
11.Borehole diameter (in-) Program,
Off: 113 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
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
(Le.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) _ Method of test: %% /DATE SITE VISITED: �
o ���� �-j '.� �'� (`
13b.Disinfection type: 70/o HTH Amount: OZ Cam b"p
i
- VISITED BY: ���� •�u Y�il/i'r�'
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