GW1-2022-10340_Well Construction - GW1_20221114

VM I(,CONS TkZeT10 T RECORD (GVV-1') For Internal Use Only:
1.Well Contractor Informntion:
14.WATER ZONES t�
[mow FROM TO DESCRIPTION +J
Well Contra for Name �J{t. fr.
t0 J l YGG Icy
NC WA Contractor Certification Number 15.OUTER CASING for mulfi-rased wells OR LWF.R d a Unable)R;
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNEss MATERIAL
fr, ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
l.J
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well construction pennies(i.e.UIC,County,State,Variance,etc) -44 fL
ft to% in'
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREENFROM To DIAMKMR SLOT SM TEICK NESs MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACE TA4ET OD&AMOUNT
Non-Water Supply Well: ft, 3 ft. • 1 5
❑Monitoring ❑Recovery ftrjq ft. �Cltii Pll Ip C
Injection Well: ft, ft
❑Aquifer Recharge ❑Groundwater Remediation l'J`
19.SAND/GRAVEL PACK if applicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EAtPLACEMENTAMHOD
❑Aquifer Test ❑StoTmwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft ft. F
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)j
FROM TO DMSCRIPTIOx color,hardness,soillrnek e, "n svq etc
D ft ft. s o W
4.bate Wells)Completed: /o- .Z)-Well D# - 33 9 lyQ ft. ft
Sa.Well Location: Phone # d PtAc4 A 5�" e Log ft fL bMkJMvElf 51MIfe-
M414K �StjD6�� y 9Bo-Z7-7-6 106 ft' )aO ft joqYi�,nFdCf,
Fam7ity/Owner Name Facility ID#(if applicable) tx0 ft• ft oj,/I(
ft. ft
/cci sa h f t+Qf c�q Liv+e
Physical Address,City,and Zip ft
ft ft.
ef
n (dA/ `12�1..REMARKS
County Parcel Identification No.(PIN) '�`+ a-T FiNtrin
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees: NOV 1 �l' L
(if well field,one lat(loagis sufficient) 22.Certification:
3S S 2F. 7�7G N l 3�• a '7�� W � � tar:. U76-wo-Al
6.Is(are)the well(s): germanent or ❑Temporary
o ertified W611 Contractor Date
Aerplain
By signing thisform,Ihereby certifythat the wells)was(were)constructedin accordance with
7.Is this a repair to an e)dsting well: ❑Yes or0 15A NCAC 01C.0100 or I5A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repairfdl out known well construction information the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
6.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 additional pages if necessary.
drilled: �'—,� > 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:rf�l �Q� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'anndd 1®100�
D 0 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
Bit Off: 5 V� 24b.For Injection Wells: Copy to DWR,Underground Injection Control (RUC) i
IL Borehole diameter: 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.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
13a.Yield(gpm) •10
JJAJ[G� Method of test: t Permit Program,1611 MSC,Raleigh,NC 27699-1611
Q�j' � ]I N V
13b.Disinfeetion type: 7D%HTH Amount: OZ DATE SITE VISITED:
vo
wow VISITED BY: ji
pr1 rP'
❑ rui-r North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018