GW1-2022-10301_Well Construction - GW1_20221114

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I .>ontractor InformRtion:
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OUTF�tCASING•formvld-casedWells ORLINIER sfe licawe
YADKIN WELL CDAAPANY,INC. F a ,:74 e w .. FROM To nrAMsi$R rffiezaysss MATERSAI
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16.INNER(:ASIlVG OR TUBING eothermal closed-Too ) ..e
2.Well Construction Permit#: 3 5 3 4;00 FROM I To I DWTETER I T333CICMS MATERLAL
Llsf all applicable well construction permits(la.tnG County,State,Variance,em) ft G j ft Q in.
E 3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DUMETLR SLOT SIZE THIC10YEss MATERIAL+..
bicultural ❑Mimicipal/Public ft. f, in.
❑Geothrrinal(Heating/Cooling Supply)
Lesidential Water Supply(single)
ft. ft. in.
❑Industdal/Commercial ❑Residential Water Supply(shared) -'
18.GROUT �.
❑lrri ation ❑Wells>100,000 GPD FROM I To MATERIAL EMPLACEMENT I%TETHOD7&/AMOUNT:
Non-Water Supply ft, ft
PP Y Well: a.� t v P"rd 17'
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK dalicableFRord I To I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage f
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Coo]ing Return) ❑Other(explain under#21 Remadcs) I
FROM TO DESCRIPTION color,hnrdness,saiVmrk 'n sae,ctr
o IDfx IS7 ft SK, �
4.Date Well(s)Completed: IO I Z =2 Well IN ! W 5 7 ft- 392 ft G�aA
Sa.Well Location: Phone # J7OV.3'10-loto ft
ft
/F_acilliity/OwncrrNance Facility M#Cif applicable) n ft. ft-
LAr3 ftftOfAii3:t.'3 1 f.r.496rk�g UM
Physical Address,City.and Zip ft ft
21.REMARKS
County Pmvel Identification No.aMi) To t' O Y-e/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/longis sufficient) 22.Certification:
�� ��'� ' N W
6.Is(are)the well(s): �Vermanent or ❑Temporary Sign a of CVeed Well Contractor Date
By signing thisform,1hereby cEnyy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �&O 15A NCAC 02C.0100 or I5A NCAC 02C.0200 O'ell Construction Standards and That a ropy
If this U a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under f21 remarks section or on the back of thisform.
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 Remadm Box).You may also attach additional pages if necessary.
drMed: C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 O:� (ft.)
For multiple wells list all depths 1fdi)erenl(example-3©200'and 2@100) Submit this G'W-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 60 (ft) ?Aa. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level Is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Sit Off: t/a SS 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC`7699-1636
12.Well construction method: AIR ROTARY
(i.e.auger,rotary,cable,direct push,eto.) 24c.For Water Suprply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health deparbnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GPD:Copy to DWR'CCPCUA a
13s.Yield(gpm) I d Method of test: Permit Pmgram,1611 MSC,Raleigh,NC 27699-1611
70%HTH
13b.Disinfection type: Amount: 1 S" OZ DATE SITE VISITED: .`_Z .
Pri re-: VISlTED BY: VP
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Form GW-1 Nortli Carolina Department of Environmental'Oualitu-Divisinn of Waf.rR,mn.rPo� *- :_�_ '.._,_,�__•;