GW1-2022-08731_Well Construction - GW1_20220408

VVEL&CONSTRIUCTION if�tfr,ICOR D (GW-1) For Internal Use Only:
L Well Contractor Ilnformation:
14.WATER ZONES P •1�--
Well Contractor Name FROM TO I DESCRIPTION l
NC Well Contactor Certification Number c 15.pUTER CASING(foraiulti-cased wets)OR LIlVER d a livable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER I THICKNESS I MATERIAL
f. ft in. r-^
Company Name S14 vi, 3340- °fob- V'r" l
y t��'' 16.DiNER CASING OR TUBING 'eothermal closed loo ]�
2.Well Construction Permit#: P("W 1- '•Q a-. ya0.T Jr FROM To DIAMETER THICIQir- 114ATERIAI. G6
List all applicable well construction permits(i.e.WC,County,Slate,Variance,etc) `f ft 89 ft (1 in.
3.Well Use(check well use): ft ft. `n. �1�
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE T1110WESS MATERIAL
❑Agricultural ❑ icipal/PublicJR
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Su ft. ft, in.
❑Industrial/Commercial ID-Residential Water Su18.GROUT
❑Irrigation T❑Wells>1OQ000 GPDFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan Water Supply Well: D ft. 4/' ft. 6,tn=e�; v t!ewf
❑Monitoring ❑Recovery it Cft, 0v� s�u ✓'
Injection Well:
❑AquiferRecharge ' " ;� OGroundwaterRemetii
B.SAND/GRAVEL PACK der livable)
❑Aquifer Storage and Re6S�I Q 2022 ❑salinity Barrier FROM To WATERIAL EMPT ACEMENTMMOD
❑Aquifer Test H r t� d1 0 ❑StDrmwater Drainage❑Experimental Technolop�y l ii ❑Subsidence ControlfL ft.
❑Geothermal20.DRILLINGLOG attach additional shcets ifnecessa'; FROM TO DESCRIPTION color,hardness,soi track in siu,eto❑Geothermal(Heating/CoolingReto n) . 00ther{explain under
o ft• 7 5` o r L v�/Yi
4.Date Wells)Completed: � 7'�2' WellID#1�f�D��� 7� ft• 66 a'� f Pd�Sd .�o at VJ
Sa.WellLocation:' Phone #33� .2 - J/� fL ft.ft. fL
a ► n• 1
Fact'lity/OwnerName rFacility ID#(if applicable) n. ft.
fir• oe., #dt RA rA&i,as OVA ft. ft.
Physical Address,City,and Zap ft ft
21.REMARKS
�'a�e-Mery
County Paruel IdentiScationNo.(PIN)
5b.Latifiide and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field;one lat/longis sufficient) 22.Certification:
6.Is(are)the Well(s): a4manent or ❑Temporary SiVktire of Cei0ed Well Contractor' Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 3No 15A NCAC 01C.0100 or 13A NCAC O2C.0200 Well Construction SYandards and that a copy
ythis is a repair,fell oul known well construction btformatlon and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 i fD
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: r24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1®100)
5'Q 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit 1611 MSC,Raleigh,NC 27699-1617
lfwater level is above casing use 11, • v
Il.Borehole diameter (in.) Bit Off: 9 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC) 9
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
(Le.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 I00,000 GPD: Copy to DWR,CCPCUA
PertiI Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: tf nG
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: (2. t a -Y 2-1
QC�
VISITED BY: