GW1-2022-00159_Well Construction - GW1_20221219

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WE eiONST1RUCTION I-+CORD QW- For Internal Use Only:
1.Well Contractor information:
m✓ d 14.WATER ZONES
Well Contractor Name FROAI TO DPSCR]IPITON
• ft ft �F/G9�� f✓•� 7
S'7 i�-h ft. K
NC Well Contractor Certification Number 15.OUTER CASING formuld-rased weIIs ORLINER da livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCI�IEss AfATERUIL
ft ft in. p�
Company Name B6/s1s �a y r��Z� .ZC��. E°�rt�, 16.�R CASIIVG OR TUBING eethermal dosed-too ) 5'
2.Well Construction Permit##: FROM TO DIAhIETIM THICIO4FSs MATERIAL i
List all applicable well construction permits(4e.UIC,County,State,i/ariance,ea) � ft IP9� ft. in.
3.Well Use(check well use): ft ft. in, a
Water Supply Well: 17.SCREEN
FROM TO DI&WELTM SLOT SIZE ------ MATERIAL
❑Agricultural ❑MunicipalRublic ft. ft. in.
1
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Indusrria]/Commercial IRL,idential Water Supply(shared) Is.GROUT
❑lrrigatlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETROD dt AMOUNT
Non-Water Supply Well: ft ft.
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EB2LACEMENTMETH0D
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRMJMGLOG fatfach additional sheets ifnecessa
JGeotlimmal(Heating/Cooling Return) ❑Other(explain under 421 Remarlos) FROM To DESCRVT10N e°I°r,h°rdims,saWrack typr,grain srsq etc
®� 'Ar ft •e Imo 76 As rW "Z.1111- 7r
4.Date Well(s)Completed:-10-96 2'c;9- Well M# S /®° ft �
f ae# -
ft5a.WellLocation: � � z�- ��� 9� ft ��fOn
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Fac(i tt§/Owner-Kame Facili/ty�II/l{1(if app&cable) ft. ft 7 +r
"1' � a� E +1S�G�s� li 7e9a�t k ft. it F d �n 2
Physical Address,City,and Zip ft fL _
bl p kL' �sRL 21.REMARKS,) AR r a
County Parcel Identification No.(PITY)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): ❑Permanent or ❑Temporary atnre of er6fied WrIl Contractor Date `
By signing thisform,I hereby cert j/y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an e)dsting well: ❑Yes or I°JNo 15ANCAC 02C.0100 or J5A NCAC 02C.0200 Well Construction Standards and that a copy
YM s is a repair,fill out brown well construction brformation and erplain the nature of the of this record has been proviAd to the well owner.
repair under f21 renmrkssection or on the backoffhisform. 23.Site diagram or additionalweil details'
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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarla Box).You may also attach additional pages ifnecessary.
drilled:. ( 24.SUBK rraT.INSTRUCTIONS
9.Total well depth below land surface: Ca.? (ft) Submit this Gw 1 within 30 days of well coin
For multiple wells list all depllrs 1fdierent(erample-3©Z00' nd2@100D y pletioII per the following:
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i10.fwater Level/s above casing,use 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below tap of casing: (ft Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: (in,) Bit Off: S_ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
(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) Method of test: .!� Permit Program,1611 MSC,Raleigh,NC 27699-I611
9 `r.%/�•
13b.Disinfection type: 70%HTH Amount: �;j,�S OZ DAT SI TE VISITED: 7 m
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vri ra- - --�- VISITED BY: