GW1-2022-10365_Well Construction - GW1_20221115

,AE� C�1�T�1i1fJC1TI�1� �� D -1) For Internal Use Only:
1.Well Contractor Information:
�Q I rV(41 i/') 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3o3(, A- ��,,�t. ft. �/�
NC well Contractor Certification Number ,S-1 O ff ft t�Z
15.OUTER CASING for multi-cased wells OR LINER if a Iicable
YADKIN WELL COMPANY,INC. FROM I TO DIAMETER TffiCIOTESS MATERIAL
3 ft. �. b/ark
Company Name -`/ ft ' eSD
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: P it
W L 2-0 2 2—o 0 '7 rt FROM To DIAMETER THICIINESs NIATERIAI.
List all opplicable well constmrction.permils(t e.UIC,County,State,Variance,etc) ' 71 fr r 1D 'Pile i�
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
TO DIAmrrER SLOT SIZE TmcmtsS MA
❑Agricultural ❑M icipal/Public ft, 6.
❑Geothcrmal(Heating/Cooling Supply) L9itesidential Water Supply(single) t. ft.
FROM
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IIr1 ation ❑Wells>100,000 GPD FROM 1 TO MATERIAL EMPLACEMENT ATETHOD&AMOUNT
Non-Water Supply Well: 0 ". 3 o ft.
❑Monitoring ❑Recovery it. ft
Injection Well: ft
❑Aquifer Recharge []Groundwater Remediafion 19 SAND/GRAVEL PACK If a Ucable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATT RUL EMPLACEMlr on
❑Aquifer Test ❑Stormwater Drainage D• R
❑Experimental Technology ❑Subsidence Control i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Rcinn) ❑Other(explain under if21 Remarks)
FROM TO DESCRIPTION color,hardness,soiltrvck 4 size,etc
ft. � ft. Ste: � �biz G S
4.Date Well(s)Completed: /0-S " Z Z4,11
we 70 ft t3 ft .So" Lr� ( lit.
5`a.W Well Location-
( �L Phone # 3534 ft ft
ft ft
Facilr�Name PadHfy ID#(if applicable) ft. ft "' 's ,.'
924 :��t4 � A RZA 'rkw-,r•a14 ft V 1 5 202L
Physical Address Ciff and Zip % ft.
5u vv,y 2L REMARKS
County fParrA Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Twell field one lat/loagis sufficient) 22.Certification:
�Iogq N R6, 47 2-70 Se- w :�e,x �6_^ Ae's"- ZL
6.Is(are)the well(s): 4ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or L71VD 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
Ifthis is a repalr,fdl out]onown well construction bnformation and explain the nature of the of this record has been provided to the well owner.
repair under#21 remala section or on the back rrf thisform.
23.Site diagram or additional well details:
e
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells may use ls having the same the back of this page to provide additional well construction info
construction,only 1 GW-1 is Yeeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnccessary,
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4/0 Z (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if&fferent(erample-3Q200'and 2Q100D Y p p
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: O (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use "+" /
11.Borehole diameter" G (in-) Bit Off: b / 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
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 WELTS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
3 ^ n Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield m Method of test: /
(gP ) p
13b.DisinfeFtion type: 70% HTH Amount: Z/p OZ DA'k SITE VISITED: 3 2 Z
o
Pri
VISITED BY: _J/�