GW1-2022-09472_Well Construction - GW1_20221014

=%LL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor wormntion:
e
/ ° 1 rl''p�d p/w 'ri,W ri 14.WATER ZONES
Wet Contractor Name FROM TO DESCRIPTION
.? G-r ft 4 6 ft. I 1 ��l � .20
106ANC Well Contractor Certification Number 15.OUTER CASING forniulti-rased wells ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM To IRIAM911R zfficKNEss MATERIAL
ft. ft in. R
Company Name 26.JIT- R CASING OR TUBING eother I dosed 100
2.Well Construction Permit#A: 2z_E ` V FROM TO Dw4nI TIICMJMss I MATERIAL
List all applicable well construction permits ti.e.UIC,County,Slate,Variance,etc) �` ft ® ft t y in.
3.Well Use(check well use): ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE TRnCICNMSS MATERIAL
❑Agricultural ❑Mimicipal/Publio ft. ft.
❑Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTATETHOD&AMOUNT
Nan-WaterSupplyWelh 0ft' 3 ft 1 , 3`lam
❑Monitoring DRecovery 3 it .27
Injection Well: ft ft a ®�
❑Aquifer Recharge ❑GroundwaterRemediation UZI e.
I9.5ANDJGRAYEL PACK if a limb C.
❑Aquifer Storage and Recovery ❑SalinityBanier FROM TO-- MATERIAL-- EMPI.ACEMENTMETHOD
DAquifer Test ❑Stormwater Drainage '
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) []Tracer 20.DRI LIMGLOG attach additional sheets ifnecessary)
ermal(Hea
Geothtmg/Cooling Retam) ❑Other(explain under#f21 Remarks) FROM TO DI sCRusxloN(color,L°rdaess 3°illroek a �e ecr
❑ �
® ft. 3 it s' p e
4.Date Well(s)Completed: "��' Z� Well ID#, P_&�� 13 ft ft. Sr.Jjh,._ /G, Q ele ' t �.
�It ®'� �� � ��ire e. _'_.n5a.WellLocation: Phone # gt139 5,,r'�
3
f� t,
C .e d a
Facility/OwnerName FadlityID#(ifaWUoable)p, ft ft
6A! ft. ft
Physical Address,City,and Zip ft 1 J U ni i
21.REMARKS
Ini�,,;�t ,�". • �
CD,mty V Parcel Identification No.(PIN) w
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field;one lattlongis sufficient) 22.Certification:
6.Is(are)the well(s): *crmanent or []Temporary
Signature of Certified Well Contractor Date
By signing thisfa m,1 hereby certify that the wall(s)was(were)constructed in accordance with e
7.Is this a repair to an existing well.• OYes or 00 15A.NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If ibis is'arepair,fill out known well construction information and explain the nature of the of this recard has been provided to the well owner.
repair under#21 remarks section or on the back ofihisform. 23•Site diagram or additional well details: a
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: ` 2A.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I 0 (ft) Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths Jfdierent(erample-3Q200'and 2Q100D
1 (ft) 24a. For All Wells: Original ,form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If waier level is above casing,vse"+"
Bit p{{; -, 03A 24b.For Injection Wells: Copy to DWR;Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
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 over 100,000 GPD:Copy to DWR,CCPCUA I
® Permit Program,1611 MSC,Raleigh,NC 27699-1611 1
13a.Yield(gpm) Method of test: �'1�� qy q ) J
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VlS1TED' �9C ` �f V
r
S1TED BY.