GW1-2022-08633_Well Construction - GW1_20220513

L+CONST1RUC LION RC �+�W-1� For Internal Use Only:
14',Vellll�Co-nntractorr IIn�form/ation:
y '[-? 14.wATERZONGS
Well Contracto ame FROM TO DESCRIPTION
�i
rI F?y'�" �p ft, 9/?a• ft 1
NC Well Contractor Certification Number 14 ,
SI 1S.OUTER CASING(for An '-cased swells ORLINER if ap likable
YADKIN WELL COMPANY,INC. FROM TO DumnmrER TEaCENMS MATERIAL
ft ft in.
Company Name 16.INNER CASING OR TUBING eathermal closed-loon)
2.Well Construction Permit#: 13 !r�•� !T] 7® FROM To I DIA warm I Tmera Ess I MATEluAL T
List all applicable well construction permits(te.WC,Counfy,State,Parlance,etc.) 4 t ft lfJ� ft In.
3.Well Use(check well use): % ft• to in.
Water Supply Well: 17.SCREEN
CP
FROM TO I DIAMETER I SLOT SIZE I TMCKrMsq MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 1B.GROUT
❑IIri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G ft. fr. -G( 6 u rcQf
❑Monitoring ❑Recovery 3 % 2,6" ft •h.sla u �^
Injection Well: R
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK rifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ;MATERIAL LACLMENTMMTHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'sdditional.sheetsifnecessary)
❑Geothermal(Heating/CcolingRetnm) OOther(explain under#21 Remarks) 1MO To DESCRIPTION color,hardness,soivracktypc�g.rdm siM ate
D fL 3—p ft s
4.Date Wells)Completed:_y Z'7-�— Well I# 3 f 0 fi /✓���Sa�f To �a v
5a.Well Location: �//kS4k Phone # ed.9VCft ODY ft eel l"I • '
ft fL
LAI B/Ltf/' t y,14,A ft ft
Facility/Owner Name Faci*ID*(if applicable)
it. ft 1'�
c���
n a� � /^
PhysicalAddress � ft. ft. J
21.R17MARTCR
Ung
County Parcel Identification No.(PIN) GG�C✓ / d �� _
0 pe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ♦v . Q� n_
(ifwell field,one lat/longis�sufficient) 22.Certification: 1
��_l 7 ?h I(Q N t �jf'3 1�j�� W n a
yam �- �
6.Is(are)the well(s): [�ermanent or ❑Temporary S' re of ed We Contractor Date
/ By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance wllh
7.Is this a repair to an existing well: ❑Yes or ° 0 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out]mown well construction information and explain the nature of the of this this record has been provided to the well awner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeMPT 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 Remarim Box).You may also attach additional pages if necessary.
drilled:, t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /4 0; (ft') Submit this GW-1 within 30 days lof well completion per the following:
For multiple wells listall depths If different(example-3(a)200'and 2®100)
Ms. For All Wells: Original form"to Division of Water Resources (DWR),
If pp ,,
f Static water level below top of casing: 7S (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use"+" �q0
11`Borehole diameter (in.) Bit Off: _ 24b.For Irriection Wells: Copy to;DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto 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 producing over'100,000 GPD: Copy to DWR,CCPCUA
3 AF4-- Permit Program,1611 MSC,Raleigh";NC 27699-1611
13a.Yield(gpm) ly Method offest: Q( Y / I -
70%HTH (' OZ D SITE VISITED:
13b.Disinfection type: Amount: � 7��
EPri re- c IS T OD Y: i