GW1-2022-10315_Well Construction - GW1_20221114

i1'�TJL+C4�IY511T�N�111I�I� tC� d� -1� For Internal Use Only:
1.Well Contractor lnformntion:
��/'p u S`�t/t7 y►"e r 14.WATER ZONCS
FROM TO DESCRD TION
Well ntractor Name
o ft. q ft. / `— exo Ca /c.s•�7p 1 Q �
fr. ft
NC ell Contractor Cettification Number 1S.OUTER CASING for multi-rased wills ORLINER rf a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
>* �-�° - rsv fI ft G� (—rI sin. sD,R-a 0
Company Name Fp,Sy� 33 16.DU4ER CASING ORTUSWG eothermalclosed-loo )
�( 2.WeU Construction Permit#: �bd PN ka FROM To DIAMETER I TMC1=SS huT=Ar.
�aList all applicable well construction permits r.e.I71C,County,State,Parlance,etc) ft ft in.
a , + 3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well: rROM ro DLkMK= SLOT SIZE TH1CICNrSs MATFAr AT.
❑Agricultural ❑Municipal/Publie ft. ft. In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) IB.GROUT
❑Irrigation = 4 >100,000 GPD FROM TO MATMUAL EMPLACENMT METHOD&AMOUNT
r Nan-Water Supply 4 9.-- "" rraK �4[-e_
OMoaitming s Recovery it ft.
Injection Well: 1
it ft.
❑Aquifer Recharge r �. � �f,;; p�C3lndwaLer Remediation
� u,n I9.SANDIGRAVEL PACK if a limble)
❑Aquifer Storage eco�;Q,t3'0G ❑Salinity Barrier FROM TO MATEMAL EhD LACEMENT1d=0D
{*� OAquifer Test OStormwater Drainage ft. ft
tf ❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLIlVGLOG attach additional sheets ifnececsa
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) W'.
TO DESCRIPTION color,hardnerr,:oivrvck -a sirs,etc.
4.Date WeU(s)Comple1erM/,0,J I, Wellim `s a ($ ft' �t^a-�/�{
5a.Well Location: Phone # -t�� y�_/�P3 �ODft' L• t a�G•.++•`�CCyl.4 iaSefYr������� - it
Facility/Owner rName Facility ID#(if applicable) ft. ft
/z ft ft
Physical Addres Fri+ s a d Zip ft ft.
21.REMARKS
,e
County , Y Parcel Identification No.(FIN) el C9 LDS O �r u
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Oe C r rc
(ifwell field,one lattlongis sufficient) 2. $cation:
r
-7 37oe)3°
6.Is(are)the well(s): kermanent or ❑Temporary re of Certified Well Contractor Date
By signing thisform,]hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well, ❑Yes or )tNo 15ANCAC 02C.0100 or lSA NCAC D2C.0200 Well Construction Standards and that a copy
l out a well construction information and explain lain the nature o the of this record has been provided to the well owner.
If this is a repair,fd known .l� p of
the
carder#21 remarks section or on the back of thus form.
23.Site diagram or additional yell 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 Remarks Box).You may also attach sdditional pages if necessary.
drilled: 24 SMITT Ug AL INSTRUCTIONS
n
9.Total well depth below land surface: y +- (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths!f different(emmple-3@ZZ00'and 2©100�
0o ft 24a' For All Wells: Original form to Division of Water Resources (DWR),
10.Stnticwater level below top of casing: ( ) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 .
Tfwoter level/s above casing,use"+"
Il.Borehole diameter v r (in.) Bit Off: G_ _ ?Ab.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
. Program,1636 MSC,Raleigh,NC 27699-1636
IZ.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 producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: r r
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount:
VISITED BY:
iental Ouality-Division of Water Resources Revised 6-6-2018