GW1-2022-10447_Well Construction - GW1_20221116

$ For1n�trnl UDnly:CONSTRUCTION RECORD (GH-1)
I.Well Contractor Information:
/ & ru tn/ /J llJ Inr✓� 14.WATER ZO
FROM TO DESCRIPTION
Well Contractor Name ft. 102 ft.
o G. V
3 3 6 9-5-7- 4rr Ll
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf a liable
FROM O DIAME ER THICIQQEss MATERIAL
YADKIN WELL COMPANY,INC. �ft ffi in,
Company Name � �� ,`-'J' 1 '
w _ 3 16.IlVNIER CASING OR TUBING eothermal closed-lao )
pp (. J �� Z(y Z &L FROM TO DIAMi 1ER THICISNESS TATERIAL
2.Well Construction Permit#: L J ft 16 r� in. 421_�
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc.) �
3.Well Use(check well use): ft 6s" ft G / m •1-� 6.IV17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THIC CNESs MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [residential Water Supply(single) ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) le.GROUT
❑Teri on ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT
Non Water Supply Well: ft. J/ ft. G!4 1
❑monhoring ❑Recovery ft. ft.
Injectiou Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK der liaable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAI ENffLACEMENTMETHOD
❑Aquifer Test ❑Storrnwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCEOPTiON color,badness,soiVroek 'a size,ate.
❑Geothermal(Heating/Cooling Rchun) ❑Other(explain under#21 Remarks) J D ft f3�
//�� ft
4.Date Well(s)Completed: /yy u'Zg'LZ• WellID#.�/�'r'' �S .� 6 � G ke
Sa.Well Location: P One # 1 %$S"'� ( fL 0 f,
- ft. ft.
S � �awK
Facility/ wnerName
Facility ID#Cif applicable) ft. R
/ ft. ft r':
ft ft
Physical Address,City,and Zip
K l h 21.REMARKS V
County 01
Parcel IdentificationNo.(PIN) // ., UrM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v`
(if well field,one lat/longis sufficient) 22.Certification:
N OOP" .�8•: -2 s'R w
"� 5�ignatore of Certified Well Contractor Date6.Is(are)the well(s): ppermanent or ❑Temporary
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
15ANCAC 02C.0100 or 15ANCAC 02C.02D0 Well Construction Standards and that a ro
7.Is this a repair to an existing well: ❑Yes or L'JNo of this record has been provided to the well owner. py
If this is a repair,fdl out known well construction information and explain the nature of the
repairunder#21 remarkrsedion or on the back ofthisform. 23.Site diagram or additional well details:
ermal Wells having the same th
You may use e back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geoth
construction,only 1 GW (add'See Over in Remarks Box).You may also attach additional pages if necessary.
is needed. Indicate TOTAL NUMBER of wells
drilled: A.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IS-0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths!f different(example-inn 200'and 2®1001
74a. For All Wells: Original form to Division of Water Resources (DWR),
J—d
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use'+ d
Bit Off:_b 24b•For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.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 C
(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 4
! Permit Program,1611 MSC,Raleigh,NC 27699-1611 y
13a.Yield(gpm) 3-l/2 Method of test: r/{I— c1 r
70%HTH a OZ DATE SITE VISITED: &-/ J- ?'L
13b.Disinfection type: IVA
Amount: _ \\
VISITED BY:
Pri cry- —
nnmental Quality-Division of Water Resources Revised 6-6-2018
Fnrm CiW-1