GW1-2022-08610_Well Construction - GW1_20220513

'E+1,L CONS MIUCTION RECORD(GW-1) For Internal Use Onty:
1.Well Contractor Information:
14.WATER ZONES
FRom TO -DEsCRVTION 2
Well Contractor Name
31f,4 `� �� o rya P• r
NC Well Contractor Certification Number is.OUTER CASING forlulti-cased'vrella ORLINER?if.a lresble r 1
YADKIN WELL COMPANY,INC. FROM O DIAMETER:` TffiCIQVEssSk,2 AMATIN
ft. is r r
Company Name
16.INNER CASING OR TUBING d lo closec
ATERIAL a
2.Well Construction Permit#: TO TSICI MS 'A�11f
,
List all applicable well construction permits(r.e.LUC,County,State,Variance,eta) 1II'. £ �/
3.Well Use(checkwell use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETLRf& SLOT,SE=Maa1IiTHICHMS-S 1MATERli1Lr
❑Agricultural ❑Mnmicipal/Public ft. ' fr
>4��-w -�
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.,
❑IndustriaUCommercial ❑Residential Water Supply(shared)
15.GROUT x'awl I�T�r i�F r
❑Irrigation ❑Wells>100,000 GPD FROM TO: H i f+MATERLIL SEMPrrACEMINTiMET[iODtaYAMOUNTy
Pion-Water Supply Well: « +
❑Monitoring []Recovery
Injection Well:
❑A urfer Recharge ❑Groundwater Remediation ¢ s
q 19.SAND/GRAVEL,PAGK,xf li hle)ti?"
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM _ 11MA-TERrAL . 71EMPI CL+MENTWMETBUDI�
❑Aquifer Test ❑Stormwater Drainage" Ri 3 `
❑Experimental Technology ❑Subsidence Cohtrol
❑Geothermal(Closed Loop) ❑Tracer 20.DRII,LINGLOG"aK&OdditioGSLsheets�if;nee�sa
❑Geothermal(Heating/Coo]ingReturn) ❑Other(explain under#21 Reinarics) FROM '* To*� olms�l�n1ON(ail taran�s�:ovmeti me;"~t"
4.Date Wells)Completed:
5a.Well Location: Phone # �$ S- - / 3 7 r pia~
-�f 7 9
i&lw (�A/�h0 ll ft: x
Facility/Owne=Name Facility ID#(if applicable) ft. by IF y `}`: r 20.,,�
Physical Address,City,and Zip ft 'ri, p \ fi Jirwrr �it !
'2L REMARKS.Jftll �
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: I
(ifwell field,one lathongis sufficient) 12.Certification
mod:
�v,��„•' ,�,�. ' '�lull Y�LV
Signature of Certified Well Contractor
6.Is(are)the well(s):*ermanent or ❑Temporary
By signing thrsforrii I hereby certify thaf the well(s)'was(xe c ;wed in accordmtce weth
7.Is this a repair to an existing well: ^as or InNo 4 @�e H 15ANCAC 02C.0100 or ISA NCAC 62C 0200*ell Constrrrchon StMao=Qnd fhat o co
s+g rr s
1f this is n repa/r,fill out)mown well consbvcdon information and explain then of the of this record has been provided to the well owner t y
repair under 01 remarks section or on the back of this form. x r y
23.Site diagram or additionalvrell details "'
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provldead" nalconstruction info
(add See Over'in Remarks Box) You may also attach edddional,pam if necessary.
construction,only 1 GW-1 is f'eeded. Indicate TOTAL NUMBER of wellsn-
drilled: L' ` 24.SUBMITTAL INSTRUCTIONS + `'�t'
9`Total well depth below land surface: 1203 (ft)` " = - r
For'muhiple wells lisp all depths If den nt(example-3@1 'and 1Q1001 Submit this GW 1 within 30 days of well complefioti per the following: Q�
;rtie. L r;
24a.,For All Wells: Original form to Dhdsiciff 6f�Wa-mr, esDumas (DWR),
10.Static water level below top of casing: (ft);.juhrmatiori Processing Unit 1617 MSC,Raleigh;NC 27,699"1617
If voter level is above casing, '-
.> ' Y ,.fix"' ,�
11.Borehole diameter (P (in.) Bit Off' , 24b:For laiection Wells: Copy to DWR,Underground Injection:Control C)
Program,1636 MSC,Raleigh,NC 27699 1636
AIR ROTARYa '
122.Well construction method: 24c.For Water Supply and Open=).00p GeotheruialrReturn Weus:kCopy to the
(le.auger,rotary,cable,direct push,etc.) county;environmental health depaft dit of the co"'yhere h tK[d'd
FOR WATER SUPPLY WELLS ONLY: i 1,
Z4d.For Water Wells producing`oyer.100000 GPD:Copy.to DWR,GGPCUA
Permit Program;1611 MSC Raleigh iNC 27699 16 gl;
13a.Yield(gpm) M thod of test: Rr L,-
70%HTH 0 OZ DATE SITE.UI ITE[):
13b.Disinfection type: Amount.