GW1-2022-10334_Well Construction - GW1_20221114

WELL CONSTRUCTION CTION RECORD(GIN-1) For Internal Use Only: -
1.Will Contractor Information:
14.WATER ZONES _
Well Contractor Name FROM TO DLSCRIYTION
NC WellContractor n Number 9 S�7 ft' �4-2-ft / %2. /,.�y d
15.OUTERCASING for multi-cased wells)OR LINER tfa lirable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TfficlalEss MATERIAL
ft, ft. in.
Company Name -
{},/ 16.INNER CASING OR TUBING `othermal closed-loop)
2.Well Construction Permit#: &1' �� FROM To DIAnMTER THICIa1ESs I MATMUAL �►
List all applicable well construction permits(i,e.UIC,County,State,Variance,etc) '` ft ft r/.x s-rn• __AV
3.Well Use(checkwell use): ft ft. in. N
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
DITrigation ❑Wells>100,000GPD FROM TO MATERIAL, EWLACEIMIENTMETHOD&AMOUNT
Non-Water Supply Well: pj "' 3
/✓ ct� a
❑Monitoring ❑Recovery �.f ft ��° ft. -'��J rr4_ 11 C" ed
Injection Well: - (�
ft. ft.
❑Aquifer Recharge ❑GroundwaterR+ �*ti4n A 19.SAND/GRAVEL PACK Ha liable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERWA EKPLACEMENT WfMOD
❑Aquifer Test ❑Storm fDh:i:+ m0,3t1M
n P : ft.
wai!er ramag� _
❑Experimental Technology ❑ t s,Q�� l.Jnp ft.
Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional.sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCIETTION calar,hardness,sofl/rocktypr,grain sae,etc
ft, ift.
�[ G7 O
4.Date Well(s)Completed: Well ID# �D`// 5,y ft' �.3-C4' /y jtneJ br�4i
5a.Well Location:
� /� Phone # a7P-7o3./._30 �s d it. ruv ft• -,ir �Se� 6 L��8o
`Z PLe- G T ti��CY��dx 0 a� G� ft. Qrp� ft
Facility/Ow nnerrName Facility M9 Cif applicable) Qr�v ft. �'Q7�--7 ft-
7 ✓1r i /�� t/l/a�'�•��
` 1 1 I\t7 �i�y /�hO� L-.GIL.Igg IS77' �° L it. /��ha_
Physical Addresses,City,and Zip �p(�l ft 10611 tL M ed 4rel t- ewv-T"'
�Q /"y lai 21.REMARKS _
County ( Parcel Identification No.(P12i)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one lat/longis sufficient) 22.Certification:
3 1;3 N 1 3 4 /:3 ardl2-
6.Is(are)the well(s): F,&;rmarLent or ❑Temporary Sign fCertifi ell Contractor Date
By signing thisform,I hereby certify thot eke wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 2IVo 15A NC.4C 02C.0100 or 15A NCAC 02C.0200 Well Construction,Standards 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 welt owner.
repair under f21 remarks section or on the back of this form.
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 TOTALNUMBER of wells (add'See Over'in Remarks Box).Ybu may also attach additional pages if necessary.
drilled: I24.SUBMITTAL INSTRUCTION:i
r -
9.Total well depth below land surface: I&0& (ft') Submit this GW-1 within 30 days of well completion per the following:
Far multiple wells list all depths 1idtfferent(example-3nn 200' nil 2Q100D
f
( J 242. For All Wells: Original fcrrn to Division of Water Resources (DWR),
10. ter Static water level below top of casing: _ ft: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
// Bit Off: a 0 © 224b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (O (in.) 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,anger,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
+13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
� R•/�'
ZN v
13b.Disinfection type: 70%HTH Amount: 3(ri+ OZ DATE SITE VISITED: C Z �
I / 3 w�tIf•
yri ra- VISITED BY: 1/ ) _
r...,.,r:W-t NWWR Denarnment ofEnviranmental Ouality-Division of Water Resources Revised 6-6-2018