GW1-2022-00849_Well Construction - GW1_20220107

VVELL CO NSTRIjCTION RECORD(tLaH-1) For Internal Use Only:
3 1.Well Contractor Information:
' y' ' l �' �,� �„! lr a,V e 14.WATER ZONES
]FROM TO DESCRIPTION
Well Contractor Name ft. ft
fd
k. ft.
NC Wen Contractor Certification Number 15.OUTER CASING for multi-rased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THiC ss I MATERIAL
Company Name r /�� 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 354 7 �"Y FROM TO DIAMETER I TffiCIGVESS I MATWUA1.
List all applicable well construction permits(i.e.UIC,County,State, etc) k. JS ft' I�1 S �n OAal v�.
k. V e�
3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT slzE THICIavEss MATERIAL
❑Agricultural ❑Municipal/Public ft. k. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Im atiori. ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 77
; ft., ` ��. �,� 64 s C/CArrt�
❑Monitoring ❑Recovery'.C ; o ft. C- ft.- Q�•7 Tt 'Le Sl'a r� sn
Injection Well: _ k k,
❑Aquifer Recharge ❑Groundwater Remediation : 19.SANDIGRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO.- MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft ft'
❑Experimental Technology ❑Subsidence Control ft. ff.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
.t FROM - TO' .DESCRIPTION color,hardness,soiitrock G grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks)- ft .
4.Date Well(s)Completed:1k '- 1( Well D# '4, 1-f ft' ' It `.I�
5a Well Location: Phone #33a- �00- 13� ft s fG `'a✓�L / Ma R���`
l AhW!JLif r� ft. H0 ft. JL='' iP� i n`
Facility IDtl(if applicable) ft. ft
Fact*10wnerName
� ft. ft
Physical Address,City,and Zip t (� ft. ft 1,.,�y.
/�• 21.REMARKS h a -
3 Cduaty -�- Parcel Identification No.(PIN) AN -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lat(longis sufficient) "" 22.Certification.• '�NR-lz 41111
3� 3 ��.g W
6.Is(are)the well(s):*ermanent or ❑Temporary
Signature o Certified Well Contractor Date
,,,,11,, By signing thisform,thereby certify that the wells)was(were)constructed in accordance with
7:Is this a repair to an existing well ❑Yes or t��o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill but known well construction information m d`erplain the nature of the a}this record has been provided to the well owies
repair under#2l remarks section or on the back of this form. 23.Site diagram'or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-l'is�eeded: 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:' 1 ! (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different,(esample-3@260'and 2@100)
5 24a. For All Wells:'Original form to Division of Water Resources (DWR),
10.Static water level below.top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwdier level is above casing,use
Bit Off: !9 ° �l 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•)_ Program,1636 MSC,Raleigh,NC 27699-1636 14
12.Well construction,method: AIR ROTARY
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
FO s Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method oftest: G
13b.Disinfection type: ' n t 1!
70%HTH Amount: „�� . OZ DATE SITE VISITED: 2-1 6 -1 f P t v
,
* �rt� VISITED BY:
Price_
N-th rarnlina'Deoarhnent of Environmental Ouality-Division of Water Resources Revised 6-6 2018