GW1-2022-00162_Well Construction - GW1_20221219

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WELL+SONS TI UC 11ION RECORD(!QW-11 For Internal Use Only:
1.Well Contractor lnformntion:
14.WATERZONES
Well Contractor Name FROA'i TO I DESCRIPTION
�•-� x
2 Q 1•�] f"C
NC Well Contractor Certification Number IS.OUTER CASING forniulti-rased wens ORLINER if a licable) e
YADKIN WELL COMPANY,INC. FROM xo nrAMaTER TffiC[INESS 9 MATERIAL
ft fh in.
Company Name 16.DW=CASING OP.TU13ING eother closed-loop)
2.Well Construction Permit 9: 3 t0 a �2-- FROM TO IM"MTER TEWIM sS rILATMAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc) ft cl'c it C S'� �1)pe_.2( P(6 Cc.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.5[ � CREE l
FROM TO DIAMETER SLOT SIZE THICIMSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
[]Irrigation OWells>100,000 GPD FROM
�� I TO 111ATERLIL EMPLACEMENTAMTHOD&AMOUNT
Non Water Supply Well: V It, 24 ft. 14 t is- b 53
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft fh
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a 'licable)
❑Aquifer StorageabdRecovery ❑Salinity Barrier FROM To MATERIALI EB1pLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage f. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal,(Closed Loop) ❑Tracer 20,DR]LLTNGLOG attach additional sheets ifnecessa
OGecthermaI`(Reating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEscRiPxloN cemc hardness,so9/rnek a svl,ern
ft ?1 ft. `f
4.Date Well(s):Completed: <( 21 OLWe11ID# 2f - -50 f 2Z ft
5a.Well Location: Phone # 0-- L o.S7 & ft
gr®-f4fi�Y'r'c/t ;o ft ft
F=wty/Ow,,kName FacMyID#[rfapplicable) ft. fL 4
• ���� �'l6 H.n P�4�`sr �� __ ft. ft:
Physical Adds,Mn and Zip ft ft.
rrs 11 t L 9 2022
J` f
County Parcel Identification Ne.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/loagis sufficient) 22.Certification:
Q o. ?�O N T 1 `f f1. �7 83 j' Wq�a
�L� L t?(�Z
6.Is(are)the well(s): Cermanent or OTemporary Sfgoainre of Certified Voll Contractor Date
Bysigning thisform,Thereby certify that the well(s)was(were)constructedin accordance with
7.Is this a repair to an existing well: ❑Yes or ANo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 llrell Construction Standards and that a copy
If this is a repair,fill out known well construction information a4d erplain the nature of the of rhls record has been provided to the well owner.
repair under f2l remarks section or an the back of this form.
23.Site diagram or additional well details:
S.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 I CTW-1 is needed. Indicate TOTALNUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I k 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Li 31 A) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths lfdifferent(example-3@200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Leval below top of casing: 100 (fti) Information Processing Uni41617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+'
11:Borehole diameter- 5_. (in) Bit Off' .0 TO 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program41636 MSC,Raleigb,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open hoop Geothermal Return Wells.-Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health deparbnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
3 Method'of test �!r!� Permit Program,1611 MSC,Raleigh,NC 27699-I611 41
13a.Yield(gpm) �^ r7
13b.Disinfection type: 7o%HTH Amount OZ DATE SITE VISITED:
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