GW1-2022-08554_Well Construction - GW1_20220513

VvTLT"CONS CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.We/ll�CContractor lnforrantion:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
Z7 ft a7`ft.
3036A pi
NC Well Contractor Certification Number '15. ft t
.OUTER CASING for ninlfi-cased wells ORLINER if a livable
YADKIN WELL COMPANY,INC. FROM DIAMETER CKNEss MATERIAL
Company Name l41 3 TG-Src-q- '7 4®S-
�•
16.DiNER CASING OR TL03ING(geothermal closed-loop)
2.Well Construction Permit#: Q 7 FROM I To I DLUWMTER TMCIDWSS MATMIIAL
List all applicable well construction permits(I e.07,County,State,Variance,elm) ft. it / / in.
3.Well Use(check well use): R ft. k7 in.
17.SCREEN
Water Supply Well: FROM To DIAMrrER SLOT SIZE THICIINESS MATERIAL
❑Agricultural ❑- Icipal/Public ft. ft. In•
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. Tn•
❑IndustriallCommercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACE MT METHOD&AMOUW
Non-Water Supply Well: ft ft. r
❑Monitoring ❑Recovery it Z ft
Injection Well: ft fL r
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROSAND/GRTO L PACK(if applicable) En�LACEMENTM=- OD
❑Aquifer Test ❑Stoxmwater Drainage r
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRII,LINGLOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Braun) ❑Other(explain under 921 Remarks) FROM xo nESCRTPzxox(color,hardness,s°vrocl1x a . a:ia ate
(� Q�y p� ft. ft
4.Date Well(s)Completed: -1�� 27 Well ID#� 117v 9T-3 7 0 fi f
[,�/� fL
5a Well Location: Phone #,Ud- 7'y0 a7 Zr 3© -reOZ 1-1 r n
���� 6,Q- Cat!f. ft ft R
`racility/OwnerName FadlityID#(if applicable) ft ft
ft. ft MAY 1
Physical Address,City,and Zip ft" ft.
Compry k t 2L REM�A�RrKS ,
fy Parcel Identification No.(PIId) S +'r M SZ i�1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(ifwell field,one lat/longis sufficient) 22.Certification:
3(' fJ O 1 N FCC). �7.1 A I w Z/ ZD ZZ q
6.Is(are)the well(s): WIrmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,1hereby certify that the well(s)was(were)constructed in accordance with q
7.Is this a repair to au existing well: ❑Yes or .5Io 15ANCAC 01C.0100 or 15A NCAC 62C.02001Ye11 Construction Standards and that a copy
If this is a repair,fd/out known well construction information and erplain the nature of the of this record has been provided fo the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details: �p
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 attach additional pages if necessary.
dulled: 24.SUBM]['TT'AE•INSTRUCTIONS
t
9.Total well depth below land surface: �012 -(ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdifjerenf(example-3@200'and 2®100D
��® ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) � �processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level/s above casing,use"+"
Bit Off: Ic. dz 3 24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
Il.Borehole diameter: (in') Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Ope I n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health deparhnent of the county where installed
I ,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producink over 100,000 GPD:Copy to DWR,CCPCUA
Pemmt Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method oftest: P%ti G-1 i I
°/ HTH OZ DATE SITE VISITED: .3�'t� 2.
VISITED BY:
13b.Disinfection type: 70 ° Amount: .3�. i
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