GW1-2022-10304_Well Construction - GW1_20221114

CONSTRUCTION CTION RECORD(GVV-11 For Internal Use Only:
p
I.Well Contractor lnforrantion:
i
14.WATER ZONES l
e _Well Contractor Name FROM TO DESCRIPTION
ft. 14'70 ft, -2 G
a�fSD A ft, qaZ ft. COA G
NC Well Contractor Certification Number IS.OUTER CASING for multi-cared Webs)
OR LINER da livable
YADKIN WELL COMPANY,INC. FRo To DIAMETER THICENESS MATERIAL
ft. ft. I in.
Company Name 16.DOM CASING OR TUBING fiieothermaiI closed-loon)
2.Well Construction Permit#: �� 7 9 51. PROM TO Inut rER THICIams 1VfATERW.
List ail applicable well construction permits(i.e.UIC,County,State,Parlance,etc) ft G iu. D G)t Pl G
3.Well Use(check well use): in.
Water Supply well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE I THICIaYESS I MATERLIL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) #esidential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft' 2 5 ' a le.-flu vvt^#J 1 L'Jx S`
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK f a livable
❑Aquifer Storage andRectrvery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control fL it:
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,soiVroek in sac,eta
❑Geothermal(Heating/CoolingRetttm) ❑Other(explain under#21Rematics)
a ft' `7 ft O.W _
4.Date Well(s)Completed:/0 1 I 7:) well ID# l`f '" gf> -] IL Sao't ft
Sa.Well—
t Phone #�1�-79�-d Yl ft,* ft.
i✓ o ej�b b���� ft ft. M y
Faclity/OwnerName Facility 1D#(if applicable) ft.
// ft ft•3� LTtl+� � Z_Qh S'i•(!sNOV
Physical Address,City,and Zip ft, ft
21.REA ARKS la �,l Prtr
k5l e, DW0000
Co'Utliy Parcel Iden�fioati=No.ON)
i
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
4, lot 19 12;_>
6.Is(are)the well(s): C*ermanent or ❑Temporary
Signatnr of Ced Well Contractor Date
By signing thisform,I hereby cen'6 that the well(s)was(were)constructed in accordmrce with
7.Is this a repair to an e:dsting well: ❑Yes or Po 15ANCAC 02C.0100 or l3ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and erp/ain the nature of the of this record has been provided to the well owner.
repair under f21 remarks section or on the back of this form.
23.Site diagram or additional well details: �
B.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 r
construction,only)
GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarim Box).You may also attach additional pages if necessary.
drilled: 24.SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: 5-30 (fo Submit this GW-1 within 30 daysi of well completion per the following:
For multiple wells list all depths!fdijferent(example-3(a 200'and 2@1001
LD 24a. For All Wells: Original form;to Division of Water Resources (DWR), Q,
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 r
if water level/s above casing use"+' ft�
ll:Borehole diameter- (�) Bit Off: (Dy 24b.For Iaiectton Wells: Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY i
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produCiDR over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
�i Method of test: Cf/�/` Permit Program,1611 MSC,Raleigh,NC 27699-1611
r 13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: n�"
VISITED 6Y:
I/if