GW1-2022-09490_Well Construction - GW1_20221014

g ICONS TRU;TION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
oc A;r 14.WATERZONES
Well ContractorN a FROM TO IIESCRIPTION
�y �y 77ft. ,* ft. .504
/ y� �. $t✓ f�o'� G
as r, ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING•for multi-rased R ells ORLDlER d a livable
YADKIN WELL COMPANY,INC. FROM TO pTAMETER TIRICKNEss MATERIAL
ft, ft i in.
Company Name 16.DINER CASING OR TUBING 'eotbermaI closed-loop)
2.WellConsh-uctionPermit#:0SNA N• .�# '��� FROM To DRAe4L+ R I THICIINFSs I MATERIAL
List all applicable well construction permits(i e.UIC,County, late,Variance,etc) / ft q ft in. soe.e)
3.Well Use(check well use): % ft' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI2E TOCICNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100;000 GPD FROM I TO MtpTZRIAL EMPLACEIVMNTM E,THOD&AMOUNT
Non-Water Supply Well: ® ft. ° ft �q, •, '
❑Monitoring ❑Recovery L/ ft W,$� �,�
®
Injection Well:
ft. ft. U
[:]Aquifer Recharge ❑Groundwater Remediation
I9.SANDIGRAVEL PACK(da livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENTM=OD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology, ' ❑Subsidence Control ft ft
❑Geothermal(Closed Loge) ❑Tracer 20.ARlI,I1NGLOG attach additional sheets iftecasarA
FROM TO DESCRIF N color,hni-dneis,soiVmck 4 gm1z scr etc
❑Geothermal(Heating/C blingRetum) 001her(explain under#21 Remark) ft ©'ft
4.Date Wells)Completed:' -9la- Well ID# .. q0 :6
5a.WellLpr�tion PI1011E # �� eP �0- �➢� ,(�: e/�� `r$ ..y- _� ' ` -si- e
�Fia�ci7itylOwnerName PadlifyID#(ifapplicable) ft ft
^� Y1v ^6�&P�` 4. ���D'9lol�� ft ft ON J A 2072
�� ft fL
Physical Addrrss,City,and ZiP.
AW
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwallfield,one lattlong is sufficient) 22.Certification:
Of, V-Y- N ram'- Jq o p Y- e, W /
6.Is(are)the well(s): @Permanent or ❑Temporary Si of C ell Contractor Date
By signing thisfonn,l hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 93`o 15ANCAC 02C.01 60 or 15A NCAC 02C_0200 Nell Construction,standards and that a copy
If this is a repair,fdl oui Imown well construction information and explain the nature of the of this record has been provided to the i,ell owner.
repair under#21 remarks section or on the back of ihisform.
23.Site diagram or additionalwelI details: o
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 Remark Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1740 (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdl erent(example-3(200'and 2Q100) i
d 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top easing: 0 (ft-) hRformation ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617 '
lfwater level Is above casing,use"+"
Bit 0f. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in-) 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..auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinuloyer 100,000 GPD: Copy to DWR,CCPCUA
13R.Yield(gpm)
Method of test Permit Program,1611 MSC,Raleigh,INC 27699-1611
° DATE SITE VISITED:
13b.Disinfection type: 71)�0 HTH Amount: 9,C. �
pri c-P-i _
VISITED BY: 0