GW1-2022-08923_Well Construction - GW1_20220912

LL 4 QNST1RUCTIQN RECORD(GVV-1) For Internal Use Only:
1.Well Contractor Information:
___e�r �,l �/ !✓n - 14.WATER ZONES i
FROM To DESCRD TION
Well Contractor Name
53u ft, 3��. 1
3039,4
G 7,0ft. 6 7
NC Well Contractor Certification Number 15.OUTER CASING fo ]ti-rased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER IMCIarEss MATERIAL
ft. in.
Company Name 16.INNER CASING OR TU13ING faeothermaaclosed-loo )
FROM TO DIAMETER TffiCIOQESS N[ATERIAL �s
2.Well Construction Permit#: F
��r�_L l� �a e..�
Lisl all applicable well construction permits(4e UIC,County,Slate,Parlance,etc) .� a c7
ft iry ft in ZJ V
3.Well Use(checkwell use): ft ft. in.
17.SCREE N
Water Supply Well:
FR011i TO DIAMETER SLOT SIZE THICIOYESS MATERIAL
❑Agricultural unicipal/Public '1 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, i
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO IMMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 'U ft. j,,L ��►
❑Monitoring 3 q o very ft ft.
Injection Well:
ft, ft.
❑Aquifer Recharge S h P i S 20 2 tGroundwater Remediation 19.SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. En"sLACE METHOD
❑Aquifer Test iMorn-sOU,Cl PrCN;aMAnMY6&waterDrainage ft ft
❑Experimerta]Technologya/NOY3iG ❑Subsidence Control it
❑Geothermal(Closed Loop) ❑Tracer .DRILLING LOG attach additional sh if necessary)
n,+} ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrork q .dn sae,etc
1 ID ft. —S�' "' i
A
d.Date Well(s)Completed: -6 - ZZWPU ID#✓Y'A P ft-
Sa./Well Location: Phone # / 0V
' V � � ft ft
ft
Facility/OwnerNQamee 0 Pacility]D#Cif applicable) ft
Sr fli �1 ft ft
Physical Address,City,and Zip
fL ft
A 14 21.REMARKS
County Parcel Identification No.(PIN) / "'v'`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �eJJ 1VV 3 lie) 610L)
(ifwell field,one ladlongis sufficient) 22.Certifieation:
2 1 ; 4 7 o N '17,i'rif- 17 4 W -7_ 6 M-
6.Is(are)the well(s): geermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)canstructed in accordance with
7.Is this a repair to an ehnsting well: ❑Yes or 15No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fdl out)mown well construction information 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 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I Z4.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: *0 ;L (ft') Submit this GW-1 within 30 days''of well completion per the following:
For multiple wells list all depths if ilfferent(example-3©200'and 1©100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: L1 V (ft.) Information Processing Unit,161,'7 MSC,Raleigh,NC 27699-1617
if waier level Is above casing,use 11, G 61
11.Borehole diameter: O (in.) Bit Off: �a 4 10 24b•For Injection 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:Copy to the
(i.e.Huger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: pp 4d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
LA r+"" Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)s ' Method of test: ,
13b.Disinfection type: 70% HTH Amount: U OZ DATE SITE VISITED: _
pri r-P-
VISITED BY: I