GW1-2022-10406_Well Construction - GW1_20221116

3'VJ aTL,CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well Contractor Information:
�1y1 �� 14.WATER ZONES
Well Contractor ame FROM TO DESClunoN
��etr'-� �Qft. � •ft. � .�.
NC Well Contractor Certification Number 0-7 ft ' Y(p x,l Py� P- ft,
15.OUTER CASING for multi- wells OSCINES if a linable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TI�CKNEss MATERIAL
ft H in.
Company Name
16.INNER CASING OR TUBING eothern+at closed-too )
2.Well Construction Permit FROM TO DTntEx TfficlavEss rtATEtuaL
List all applicable well construction permits(4e.UIC,County,State,Variance,eta) I
ft. ZA it to 0 in. l�,y_ r
3.Well Use(checkwell use): ft. it. in.
Water Supply Well: 17.SCREE N
FRons TO DIAMETER SLOT SIZE THIC10ress MATERIAL
❑Agricultural ❑Munioipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. In.
❑IndustriaVCommercial (❑Residential Water Supply(shared) 18 GROUT E
❑Irrigation ❑Wells>100,000.GPD FROM I To MATERIAL EMPLACEMENTMMTHOD&AMOUXT I
Non-Water Supply Well: ft. ° ft eA,
❑Monitoring ❑Recovery it �° ft
Injection Well: ,�@�•`SlJid ty�� ✓
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
I9.SANDIGRAVELPACK da linable)
❑Aquifer Storage and Recovery ❑salinity Barrier FROM TO MATERIAL EM PLAUMZENTM ETHOD
❑Aquifer Test ❑Stormwater Drainage.
❑Experimental Technology ❑Subsidence Control ft•
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheetsifnecessa
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarics) xrxOM TO DESCRIPTION color,hardness,soil/rock a .'n srse etc.)
ft. 4t 50 ►. i
�
4.Date Weil(s)Completed: iO-7 tot WellID# A A�—I s_y Ze R � �//
5a.WeULocation: , �I eel' /� of �wq l
Phone #33G- ;° �
• If'rrzx��� Wr�rs��h �iG—�q�-f�D�t 3 ft ft
F tlity/Owner Name Facil]D#(if applicable) ft. ft
Physical Address,City,and Zip ft ft
21.REMARKS al j
Q. Q it.lS
County Parcel Identification No.(PId)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ({({({�®
(ifwell field,one lat/long is sufficient) 22.Certification: '
d
6.Is(are)the well(s): Permanent or ❑Temporary S' a of C ed Well Contractor Date
I
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well' ❑Yes or *o 15ANCAC 02C.0100 or I5A HCAC 0.2C.0200 lYell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 421 remarkr section or on the back of this form.
23.Site diagram or additionalwoU details: 1
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 j
construction,only 1 GW-1 is�needed. Indicate TOTAL NUMBER of wells (add See Ovee in Remarla Box).You may also attach additional pages if necessary. I
drilled:- G ° 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surfacer (ft') Submit this GW-1 within 30 days of well completion per the following: 1
For multiple wells list all depths lfdifjerent(example-3@200'and 2@100D
�% 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Statiewater Ievel below top of casing: /`�• (ft) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use
Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(LUG)
11.Borehole diameter: (in) Program,1636 MSC,Raleigb,NC 27699-1636
AIR ROTARY ,
12,WeIl construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyte 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;C CPC UA
f 13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
� � �'��//
o DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: �o OZ
Pri ca- VISITED BY:
­n_41_7 mnnfal n) i;t.. n,.,.;nn of W�}a.r Recnnrnnc Do..;�od 61._7f170