_Well Construction - GW1_20230315 (69)

�ONS T.I UC 1T1I+C N RECORD For Internal Use Only:
1.Well Contractor Information:
14.WATERZONES
Well Contractor Name FROM TO DRSCRIPTION
�!��' r;4 ft, 210 fr. 30 a FeA
ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi-rased we➢s ORLIIVF.R if a livable
YADKIN WELL COMPANY,INC. FROM,' To DIAMETER THICTINEss MATERIAL
ft. ft in.
Company Name ,�
I ;�l
16.INNER CASING OR TU131NG eothermaI closed-loon)
2.Well Construction Permit#p:d,tsAt E= -0t(.3 y)_ `2-p ZZ FROM TO DIAMETER THICraiMI S MATERIAL
List all applicable well construction permits(r e.EUC,County,State,Parlance,etc.) °p ft. Q/ ft G !� in. �A��. P
3.Well Use(check well use): ft. I V ft. in. {✓
Water Supply Well: 17,SCREEN
FROM TO DIAMETER I SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industdal/Commercial ❑Residential Water Supply(shared) --- GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO n1ATMUAL Ent LACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 3
❑Monitoring ❑Recovery it ft.
Injection Well: 3 a 7 &-cmdremri9� s
❑Aquifer Recharge ❑Groundwater Remediation ft ft
❑Aquifer Storage and Recovery ❑Salinity Barrier I9.MM/GRAVEL PACK(if applicable)
FROM TO MATERIAL En2P1ACEIiNTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRnJMITGLOG attach additional sheetsifnececsa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardnew,soilfrcrktypa M.in sae,°tr
® ft 90 ft ..5®c 1
4.Date Wells)Completed: .Z a Well ID# 40 ft 2 V Z ft Gran .+.c
Sa Well Location: P�'•�e'. a b, ft ft
Phone # �zr 7-r4-*7-7:r
61
• ft ft
Facrlityyllo— ame Facility
IIDACifapplicable) ft ft `.
r$�S9 Uri10i, IQ& C14kdt1"1xf(e_ ft' ft ..y =
Physical Address,City,and Zip ft ft.
21.REMARKS
County lY Parcel Identification No.(Plt4) "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one brt/longis sufficient) 2.2.Certification:
6.Is(are)the well(s): UrFierrmanent or ❑Temporary Signatu a of Ce ` ed Well Contractor Date
Ey signing thisform,]hereby certify that the well(s)was(were)constructed in accordmrce with
7.Is this a repair to an existing well: ❑Yes or a4l, 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction,Standards and that a copy
Ifthis is a repair,fill oui knawn well construction Information and explain the nature of the of this record has been provided to the N ell owner,
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well 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 I GW�is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box),You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth-below land surface: l0:? ft.
For multiple wells list all depths If different(example-3 r©200'and 2@100) ( ) Submit this GW-1 within 30 days of well completiou per the following:
10.Static water Ievel below top of casing:
'S'Q ft. 24a. For All Wells: Original farm to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: '��� 24b.For Injection Wells: Copy to DWR,Underground rnjection Control JUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
(i.e.auger,rotary cable,direct push,etc.)
24c.For Water Supply and Open-Loop Geothermal Return Wells-Copy to the
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,CCPCU
13a.Yield(gpm) 30 Method of test: A%C Permit Program,1611 MSC,Raleigh;NC 27699-1611
70°/ HTH i 10 OZ DATE SITE VISITED:
13b.Disinfeetion type: ° Amount:Pri rr-^ VISITED BY: � r\S'd^