GW1-2022-09540_Well Construction - GW1_20221014

WELL rCOFS T1RUC TION RECORD CORD(GIV-1) For Internal Use Only: i
1.Well Contractor Hn-formation:
(0f Md w f z> 14.WATER i ONES
FROM To DESCRIPTION
Well Contractor Name
3 0*S(A ft. ) .7G 0- '761
® ". q G ft. 3
NC Well Contractor Certification Number IS.OUTER CASING for mulfi-rased-wells)ORLINER if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
S-5 ft. la in. �. ®It bll"k
Company Name 16.]NNER CASING OR TUBING eothermal rlosefl-loo )
2.Well Constr uctian Permit#: /r•� FROM To DIAMETER THICI04Ess M&
List all oppllcable well construction pe"70s(Le-UIC,County,State,Mariance,err) z ft it d' in.
3.Well Use(check well use): I ff' `n' w (,1— .
Water Supply Well: rR SCREI1V
I7t011S TO DIAMETER SLOT SIZE TffiCICIYESS MA•rFn�ai.
❑Agricultural unicipal/Public ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1B.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO TUTEMAL EMPLACEMENTIISETHOD&AMOUNT
Non-Water Supply Well: L') ft. ft.
❑Monitoring ❑Recovery it. C� ft.
Injection Well:
ft. ff.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAPID/GRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI.ACEMENTMETHOD _
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheetsifnevessa
❑Geothermal(Heating/Cooling Ratum) ❑Other(explain under#21 Remarks) FROM To DESUMMON mlar,hardness,S611/mcktype,gnihi she,dr-
0
ft. v ft (� 1 L` a
4.Date Well Completed: Z Z-WellID# —Q 't9 ff' 21 ff' aSAL 6-re.40ru
+ tG
Sa'.Well Location, Phone # ViA
d0 ft ft ;
Faciity/OwnerName Facility ID#(if applicable) ft• ft
k*'e—qe-J L/'lI('(1- it. ft O C T 1 ix 2022
Physical Address, ,and Zip ft ft. - -- - -
�r➢Y3 21.REMARICS '
^ t:
County Panel Identification No.(PIN) M 04
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 r%E �0 LI at)
(ifwell field,one lat/long is sufficient)i 22.Certification'
��A N 0� �// W Z
6.Is(are)the well(s): I]Yermanent or ❑Temporary Signature of Certified Well Contactor Date
By signing thisform,1 hereby certi)�that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an e3dsting well: ❑Yes or I I0 15ANCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction SYandards and that a copy
If this is a repair,fill out)mown well construction information and erplain the nature of the of this record has been provided to the well owner:
repair under#21 remarks section or on the back ofthisform. S
23.Site diagram or additional well details: �-
You may use the back of this page to provide additional Well conshuction info
B.For Geoprobe/DPT -1 Cln ed ed. I irateGeot i TAmal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary. ~
construction,^^'•'1 GW-1 is needed. Indicate TOTAL NiTMBER of wells e
drilled: 1 M.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d�erent(example-3@200'and 2©100) lr
ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"II U g.� 1
�(In)'Nit Off: -C•• %-�
11.Borehole diameter: 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.auger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: �l I 24d.For Water Wells producing over 100,000 GPD: Copy.to DWR,CCPCUA
13a.Yield(gpm) 3
Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test:
o DATE SITE VISITED: 1 I�a m �2-
13b.Disinfection type: 70/o HTH Amount:_ OZ
0 i s A Q VISITED BY:
Prim^ `�t�6�-= '•�
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