GW1-2022-08730_Well Construction - GW1_20220408

N,ELL i(QNS 1MUCTIQN RECORD(GW-1) FFonternal Use Only:
1.Wctl Contractor Innfforrmation:
T/7 f 14.WATER ZONES
Well Contractor Name ; tt, T 7X' ft DESCRIPTION '
17 7
3 o 3 ( 14 ft. 's ft
NC Well Contractor Cutification Number
15.OUTER CASING for multi- sed webs OR LINER tf a livable
YADKIN WELL COMPANY,INC. FROM TO nIAM¢TER Tm[cta3Ess MATERIAL
Company NameJ
p� 16.]NNM CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: r' '.•S r ts.Zl0 :77 FROM xo niArHrER tHIedlavrsrys MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,eta) . ft, ft ( in. S�( at V
3.Well Use(check well use): • ft. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICIMSS MATERIAL
❑Agricultural ❑Municipal/Public ft. fr. in•
❑Geothermal(Heating/Cooling Supply) WR/esidenti9]Water Supply(single) t, tt.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 3 ft. 41wi,
❑Monitoring ❑Recovery 3 it ft. + .� �'. t• p.+�•
Injection Well: ft. fL
❑Aquifer Recharge 2%roundwater Remediation
u. 19.SAND/GRAVEL PACK tt a livable)
❑Aquifer Storage and RecaVery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRehrm) ❑Other(explain under#21Remarks) FROM To DFSCPJP710N eat°r,huanm,:°iurock n:im,etc.
/' r 9 ft S I J K/
4.Date Well(s)Completed. - '!,� Well ID# p s- ft' 3te) ti" 6_. - S,e
5a.Well Location: Phone # v�
1t ® - ft 4rQ G Vvft ft
Facility/OwnerName Facility ID#(if applicable) ft. ft
a ft. ft
ft ft.
Physical Address,City,and Zap
le,y, 21.REMARKS
County Parcel Identification No.(PIN) qew 6 ,r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one lat/longis sufficieat) 22.Certification:
6.Is(are)the well(s): I,yYermanent or ❑Temporary ignatare of Certified Well Contractor Date
f By signing thisform,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �IVo IBA NCAC 02C.0100 or I iA NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out blown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under f121 remarks section or on the back of this form.
23.Site 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 G I is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: -y 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /a 02 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(a)200'and 2@1000
"� 24a. For All Wells: Original form to Division of Water Resources (DWR),
f 0.Static water level below top of casing: / (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use 11".C. Bit Off: : i. 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in) Program,1636 MSC,Raleigh,NC 27699-1636
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.) 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm)_ N Method of test: A,f•
13b.Disinfection type: 70%HTH Amount: 3 (o OZ DATE SITE VISITED: /- w
Dri c-P VISITED BY: D56 t�r�:-ra r I"
-0
-11, T?_;c 4 A-A-,)nt a