GW1-2022-09491_Well Construction - GW1_20221014

VIKIL CONS 1RUC 110N R,C Off' (G'VV-11 For Internal Use Only:
I.W antracror n_sormntio ��'
14.WATER ZONES 1
We]IContractorName FROM SCRIPTION
TO DE
ft, it. 1
NC Well Contractor Certification Number 15.OUTER CASING for IS]ti-rasa d wells ORLINER if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER MCQVEss MATERIAL
% ft. in.
Company Name 16.INNER CASING OR.TUBING g eothermal rlosed loo
2.Well Construction Permit#: FROM I To DIANIn7m rffic[avrI . M4ATERIAL
List all applicable well construction pe�mi(r�(i e''L3 C County,Slate,T,arhmce,eta) ft ft ` �� in.
3.Well Use(checkwell use): ft, in
17.SCREEN
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE I TMOCIMSS MATERIAL
R<gdoultural ❑Municipal/Public ft. ft. ln•
❑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 MATERLAL EMPLACENIENTAMTHOD&AMOUNT
Nan-Water Supply Well: ft ft
[]Monitoring ❑Recovery ft ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑salinity Barrier IMOM TO MATERIAL EWLAcnMENTm=. OD
❑Aquifer Test ❑Stomiwater Drainage ft. f•
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRMLTNGL0G attach additional sheets ifnecesiaryl
FROM TO DESCRIPTION solar,hardness,soiUrork 4 sirs,et)
❑Gethermal(FieatinglCOolingRetum) ❑Other(explain under#21 Remadss) ft ft
4.Date Wel(s)Completed:.?--- k 22- Well im ft ft
5a.Well Location:
/.. Phone # 314'Z L 7 -AP ft ft 1 !}_'' �` 1"� n'�9� �,•c... M
Facility/OwaerName FacilifyID#(tf applicable) ft. ft
' ft. #t b� �
a i j SFFrRGr .ups � ,6/�4rnloraivyi� - C�
Physical Address,City, dZip ft
.. 21.REMARI{S t T,i I
ParrelIdentifration,No.(P]b)) �✓ e�°� ®�'' +`j
,County . . },
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees: �� _� '��'
(ifwe➢field,one Iat/lougis sufficient) 22.Cer eation:
. 1 o rat :mil N -�y p-
2 9® IT m
6.Is(are)the well(s)::fleeermaneut or ❑Temporary Signature Certified ell C tracto i r Date '
By signing thisform,1hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing Well: G}fes or 8No ISANCAC 02C.0100 orl5ANCAC 02C.0200 Well Construction,3tandards and that a copy
If this Ls a repair,fdl oul Imown wall construction fnformotion andexplain the nature of the afihis record has been provided la the well owner,
repair under#21 remarks section or on the back ofthisform. 23•Site diagram or additional Well details:
You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
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. p
drilled: 24.SUBMrrTAL MSTRUCTTONS
9.Total well depth below land surface: J-0 Z_ (ft) Submit this GW-1 within 30 days of well completion per the following: C
For multiple wells list all depths Ifdfj9erent(example-3@200'and 2®100D
�� (ft) Isla. For All Wells: Original!form to Division of Water Resources (DWR),
10.Staticwater level below top of casing: Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
/ Bit Off; , 2-3- 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
II.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
(ie,auger,rotary,cable,direct pusb,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producina,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of testA.
Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: _ _
VISITED BY:
Pei rr��—
_ E chW buality-Divkinn nfwnfrrI?_nnrres Revised 6-6 2019