GW1-2022-00850_Well Construction - GW1_20220107

EA L C0NS TR'UCTI',4DN RECORD JGW-D For Internal Use Only:
1.Weal Contractor information:
U/1 l �iaU'z 14.WATER ZONE,S
FROM TO DESCRIPTION
Well Contratett�orName ft, ft.
3 J k2_ft ft. ft
NC Well Contractor Certification Number e i
15.OUTER CASING 11or aiulti-cased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
3�� !`� � 16.INNER CASING OR TUBING(geothermal closed-too �
2.Well Construction Permit#: FROM To DIAMETER THicmasS MATERIAL
List all applicable well construction permits rLe.00,County,State,Variance,etc) ft• U 1 ft. 1- in. ' Q- l �/>
3.Well Use(check well use): ft. ft' in. `' C' -�
17.SCREEN
Water Supply Well:
FROM . .TO DIAMETER IA SLOT SIZE THICKNESS MATERL /n
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Kesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 7 ft. �n G1t� L C4 t !/CArto
❑Monitoring ❑Recovery 3 ft 3o ft- n V,y'i u p
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft
❑Aquifer Storage and Recovery QSallniTy 19.SAND/GRAVEL PACK(if applicable)
Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiVrock ain size,etc.)
] 0 It
t - ft. A
4.Date Well(s)Completed: / ;-x� Well ID# 0 -64 2L f 1 fL 5-it ft' rA
sa Well Location: Phone.#3/1F%4QJ T3/2. t ft d�- rr. f
q*I#%,'.CA ft. /t S ft ✓�'� (f �► !
Facrity/Owner Name Al i f-k Facility M#(if applicable) ft. 7 ft f
fL ft.
Physical Address City,and Zip ft f
AN r
CL1 21.REMARKS
County Parcel Identification No.(PIN) 4+�
5b.Latitude'and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell5eld,&; elat/longissufficient) 22.Certification•
�a N sz`/ 11 36 W lei- 2-�1
6.Is(are)the well(s):Aermanent or ❑Temporary Signature of Certified Well Contactor Date
JJ,,,,�� By signing thisform,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy ,
If this is a repair,fill out known well construction information explain the nature of the of this record has been provided to the well owner. V
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page tc provide additional well construction info
8.For Geoproti DPT or Closed-Loop Geothermal Wells having the same r
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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: ✓ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(example-3©200'and 2@100�
3s,e ft. 24a. For Ali Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter. (in.) Program,
Off: e ® S 24b.For Injection Wells:Copy to;DWR,Underground Injection Control(IUC)
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
(ib.auger,rotary,cable,direct push,etc.) 4.
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
t r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test d�6�: i 00
o ?)� DATE SITE VISITED: / 0 --�
13b.Disinfection type: 70/o HTH Amount OZ .�
Pri r-P VISITED BY: (/ 0