GW1-2022-08613_Well Construction - GW1_20220513

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`L Cv�NSTRNC'TI+IN��,C RII, 0"IV- i For Internal Use Only: p
1.Well Contractor formation:,
ef-at Val 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
S�'I ~/1-- Ott• t � I Slon
NC Well Contractor Certification Number 15, UTER CASING for multi-eased W ORLINER U a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER T8It3INEss larA&RIAL
ft, ft. in.
Company Name
66 ,ag 16.U04ER CASING OR TUBING eothexmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICIUMS MATERIAL
List all applicable well construction permits rLe.E1C,County,State Tlarionce,etc-) l ft ft /' [m in. S V/J r1 e 0 uc_
3.Well Use(ebeckwell use): % ft D J in.
1 dt r
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TffiCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, io.
❑Geothermal(Heating/Cooling Supply) N(zsidential 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: t7 ft. Li . ,y { Pau r
❑Monitoring ❑Recovery 11 ft ft. L?fi1�c ,+ C f h7
Injection well:
ft. R
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf a livable)
❑Aquifer Storage and Recovery ❑Salinity Bamer FROM TO MATERIAL EAU?LACrMENTM=01)
❑Aquifer Test ❑Storrawater Drainage ft'
❑Experimental Technology ❑Subsidence Control ft ft. c
❑Geothermal'(Cltised Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heatiug/Cooling Betum)- ❑Other'(explain under#21 Remarks) FROM
xo DESCRIPTION color,hardaess,eoVrock tiu sire ett
6 ft. ft
4.Dattbwell(s)Completed rh� Well W# — lf F It. ft
5a Well Loca`tion: Phone # BaX�- /l/ '7Q 31 fL �a ti ��
ft ftIf M
Facility/OwnerName Facility ID#(if applicable) ft' ft
MAY 1
0 44 P,
Pbysieal Aadress,city,aria tip
a to pJ� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S�
(ifwell field,one lat/longis sufficient) 22.Certification:
N - �R, 5 73 wqn
Lf—
6.Ls(are)the well(s): erm inent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,l hereby cer*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes or *0 ISANCAC 02C.0100 or 15ANC4Ci02C•0200 Well Construction Standards and that a copy
1phis is a repalr,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair render#21 remarks section or on the back of this form..
23.5ite 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).:You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V O� (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(f dierent(example-30a 200'and 2@1001
�0 o% 24a. For All Wells: Original foim to Division of Water Resources (DWR),
10.Static water level below top of easing: (ft.) Information Processing Unit 16 7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter �s (in.) sit Off' �5. R 5- 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Ia C� 12.Well construction method: AIR ROTARY 24c.For Water Supply and Open`-Loop Geothermal Return Wells:Copy,to_the
(i.e.auger,rotary,cable,direct push,etc.) bounty environmental health department of the county where in§telled
A FOR WATER SUPPLY W LLS ONLY: 24d.For`Water.wells producinaiover 100,000 GPD: Copy to DWR,CCPCUA,--
t Permit Program;1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ✓ 3 Method oftest: /
70%HTH OZ ,, DATE SITE VISITED: ,e2'L 7 Q- I
13b.Disinfection type: Amount:
VISITED