GW1-2022-08850_Well Construction - GW1_20220912

`j��'j�T 7.,-ICON`5TRUCTION RECORD UW-1 For Internal Use Only:
1YP�1:
1.Well Contractor Information:
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�0-0 U,),,L y n-DN^G t�. 14,WATER ZONES'
Well Contractor Name FROM TO DESCnn'TION
NC Well Contractor Certification Number 15.OUTER CASING'for niulti-rased wells ORLTNF.R if a licable
YADKIN WELL COMPANY,INC. xROM To ,,1 /niAa�T{ER I-.
TI�c[a4Esi MATE
CompaayName 7 v��"
16.INNER CASING OR TUBING ecthermzl closet-loo '
2.Well Construction Permit#- b FROM TO DIMOMrrER TST TMCII�'SS MATERIAL
List all applicable well construction permits(ie.IIIC,County,State,Trarlanee,eta) ft. rn•
05
3.Well Ilse(check well use): ft. ft. ia.
17.SCREEN
Water Supply Well: FROM TO DIAMSrER SLOT SIZE TSICIMESS MATERIAL. `-
❑Agricultural ❑Municipal/Public ft. ft. In•
❑Geothermal(Heating/Cooling Supply) ' jillZesidential Water Supply(single) g, ft. In.
❑Industrial/Comnercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM To MATERIAL EWIACEMENTMETOOD&AMOUNT'
14 Non-Water Supply Well: a ft. ft. sN cl,Cl+rt a rli.. ,C_
❑Monitoring ❑Recovery ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Ban:ier FROM To MATETTAL EMPLACEB(M-NT W=OD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control M ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRUZMG LOG attach additional shuts if necessi
❑Geothermal(Heatmg/Cooling Betam) 00ther(explain under#21 Remarks) '0' To DESC RIMON coluq hardness,solllrorlc a ..a sia,eta
ft ft. r
4.Date Wells Com leted. DO Well ID#�P"� f 1,' va(} p w �t � 70 ..: Jr � ��
5a.Well Location: Phone #���'�-73"�0� b IL �.� ft ,� �' w�%� "'� -!{-:
ft ft.
Famlity/OvmerName Facilify]D#(rfapplicable) 149, ft 3e ft. - t
NJ B
lbpu
Physical Address,City,and ft
21.RLTJARTCS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
dwell fief one lattlongis sufficient
(' d, ) Z2.Certification
'
6.Is(are)the well(s): *ermanent or ❑Temporary S• ertified Well Contractor Date,
By signing thtsform,I hereby certify that the well(k)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a co
7.Is this a repair to an eadsting well: ❑Yes or �Io p31
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
re
pair rmderZl remarks section or on the bock ofihisform.
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 GW-1 is needed Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages Unecessary.
drilled: 24.SUBMITTAL 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 lfdifferent(emmple-3()a Z00 and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levbl below top of casing: y (ft)Ifwater level is above casing,vse Information Processing Unit,I617 MSC,Raleigh,NC 27699-1617
"+" �r
G S Bit Off: (� 24b.For Lniection Wells: Copy to DWR,Underground Injection Control(IUC) J
11:$oreholediametem t (in.) Program,163 6 MS C.Raleigb,NC 27699-163 6 0
ti
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto 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'oyer 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) U Method of test:
70%HTH Oz DATE SITE VISITED:
13b.Disinfection type: Amount:
pr7 r,P rJ m VISITED BY:^ C^, -
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