GW1-2022-10441_Well Construction - GW1_20221116

CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Inforp re
y-}7y( e-I_S ).c V-Cp Nam_ j 0 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft
NC Well Contractor Certification Numbs 15.OUTER CASING for multi-cased wells ORL R 11i if ap livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS TERIAL '1
Company Name s� ;�f•�'�i ' )tic ,),
16.INNER CASING OR TUBING eothertnal closed-loo
2.Well Construction Permit#: (�i G r Zi`y:2 '? FROM TO DUME F_R T$ICIOVESS MATrurer.
List all applicable well construction permits(ae.UIC,County,State,Yarionce,etc) ft ft in.
3.Well Use(check well use): ft ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑ Ictpal/Public ft. ft. in. /
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in. 4'
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 1B.GROUT
01ifi ation ❑Wells>100,000 GPD, FROM I TO MATERIAL. EMPLACEMENT NIETHO &AMOUNT
Non-Water Supply Well: ft. ft. C� 't LlM
❑Monitoring ❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwster Remediation ft ft
19.SAND/GRAVEL PACK rf a livable) t ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI.ACE6 ! OD
❑Aquifer Test ❑Stormwater Drainage fr. ft. 1 v t�
❑xperimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sh is s races `
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color hams,t e size,ctc
G����'I �2 n O ft r 4-Lease
4.Date Well Completed:d / e , # AA P—44C50 ft' ft K �� a
5a.Well Location:
P one#q/�-G��-26I7 - ft e�
� Do &
Facility/Owner Name Facility M#Cif applicable) too fL ft- �� C aAt
K
Physical Address,City,and Zip it ft.
/ 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlongis sufficient) 2.Certifica n•
le
6.Is(are)the well(s): B'lsermanent or ❑Temporary Sign e o citified Well Contractor Date
/ ing thisform,I hereby certify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or My ANCAC 02C.0100 w•15ANC4C 02C.0200 Well Construction Standards and that a copy
If this is a rValr,fdl out known well construction b1 ormation and erplain the nature of the of this record has been provided to the well owner.
repair tinder#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 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: 6 �t (ft-)
For multiple wells list all depths ifdiffermt(eramp/e-3@200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
f 0 V (ft. 24a. For All Wells: Original form to Division of Water Resources (DWR), Q
if Static water level below tap of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above rnsirtg;use L
Il.Borehole diameter- (d (in.) BIt Off: s 0p 'T 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) �1
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health departrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: �Q I- 24d.For Wager Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:/► YA Permit Program 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
zz-
Pri re- VISITED BY: �.yi