GW1-2022-08861_Well Construction - GW1_20220912

WEL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
1Ve11 Contractor Information:
i i 5&Se (MMe- . KWATERZONCS
Well Contractor Name FROM TO I DESCRIPTION
So ft. 1.5 S
'30 3 $' - ago ft. �7f ft I s f NC Well Well Contractor Cettificetion.Number 15.OUTER CASING for mulfi rased iveDs ORLINER if a livable
YADKIN WELL COMPANY,INC. FROM xo DIAMETER THICENEtis MATERIAL
+l fL 13 ft' 4C.f; -in 5DR-a I Iv c
Company Name /� 2 16.WER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: PA 2.0 ag !/qc( FROM I TO I I)LkM ER I THIc1 MS I MATERIAL
Lust all applicable well construction permits(i.e.EUC,County,State,Variance,etc) ft it in.
3.Well Use(checkwell use): ft ft, in.
W Su 17,SCREEN
PP1Y Well: FROM TO DIAMETLT2 SLOT SIZE 7'AICtOYEss MATERIAL
cultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENTATETHOD&AMOUNT
Non Water Supply Well: it /� ! ft. e-'how to�ni M /ee
❑Monitoring ❑Recovery ft. ft.
Injection Well- ft. f
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT TtEEMOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRII IIlVG LOG attach additional sheets if necrssa
❑Geothermal(Iieating/Coolmg Return) ❑Other(explain under#21 Remarks) FROM I To DESCRXPnON color,hw-dnen,soitfrock o sae,etc.
/ 2 j��•� ft.
4.Date Well(s)Completed:0� 19D9 "Well �IMAM-/Vj '70� � 2 It Oww� rt- e- �ee �o/e�
Sa Well Location: Phone # Jsit►'�°�t:�-2y1Z J;S fL ISq G,,...,��e
Facility/ erName FacilityyID#(if applicable) ft. ft
Physical Address,(Sty,and Zap ft ft - ;•
21.REMARKS -
ParcelIdenti£cation No.(PIIT) J:: K',>: 1jr.;,
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lat/long is sufficient) 2.Cer' tin:
6.Is are the wells: br1rmaaent or. Mem orary S' Certified Well Contractor' Date
_� signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to pan existing Well' ❑Yes or I�VD ISANC2C 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and erp/ain the nature of the of this record has been provided to the well owner.
repair under f2l remarks section or on the back ofthis 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarits Box).You may also attach additional pages if necessary.
drilled: NIA 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) t t
For multiple wells list all depths tfdi�'erent(example-3Qa 200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
Z4a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S (ft.) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
7; Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigb,NC AIR ROTARY '�7699-1636
12.Well construction method: 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 lover 100,000 GPD:Copy to DWR,CCPCUA
/'t�" Permit Program,1611 MSC,Raleigh,NC 27699-1611 /�� � �y*
13a.Yield(gpm) Method oftest: I Fd✓ Cftli#'1r&
70/c HTH OZ
o ' 2 DATE SITE VISITED: -7-I 2-2-
13b.Disinfection type: Amount:
VISITED BY: