GW1-2022-01031_Well Construction - GW1_20220107

FELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
+Tlrle ln/ Xro WA 14.WATER ZONES
Well Contractor Name FROM TO DRSCRIPTTON
3036,E g® ft. 4/ ft. IZ,I
NC Well Contractor Cettificat on Number `�Y9 fL rro IL ,S-0
a OUTERCASEIWKG for multi-cas'edwells OR LINER Bp Hcable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TMCENEss MATERIAL
ft: % in
Company Name
g 16. CASING OR TUB eoflarmal closed-loop)
2.Well Construction Permit#: �'✓S-A/--d X(`1 f'19aX FROM To DIAMETER 8 MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta_) j R #7
3.Well Use(check well use): ft. fr' tn.
17.SCREEN
Water supply well:
1 ROM TO DIAMETER SLOT& THIC 01ESS MATERIAL
L S
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft it n � n
❑IndustriaUCommercial ❑Residential Water Supply(shared) IS.GROUT V.
131trigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ; fL C
❑Monitoring ❑Recovery ft.
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ft f
19.SAND/GRAVEL.PACK da livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRII,LING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DItSCRIPTTON color b�raa�,soil/rocktypc�graini etc
ft. q0 fL
4.Date Well(s)Completed: �672 2 well ID q(f ft 06 S- %f
5a.Well Location: Phone #33G-'i��'���♦Il fL
r , ft. fL
' �Go I"!` �ClR/h7Qit �G (Iu^-e< r`;;• 'F�r--=c; P---r-
Faoility/Owner Name Facility ID#Cif applicable) fL ft.
/9 ally &A fL fL .J A N 7 7o21
Physical Address,City,and Zip M ft.
LIA
Cow ParcelIdentifi cation No.(PIN) 0./ G Vy 6i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lattlong is sufficient) 22.Certification:
3a. Lf!SL8-L N 912 4M 1337 W /.2-2
6.Is(are)the well(s):Aermanent or QTemporary Signature of Certified Well Contractor Data
By signing thisform,I hereby cerdfy that the wells)was(were)constructed in accordance with
7.Is this a repair to an erasting well: ❑Yes or o l fA NCAC 02C.0100 or I iA NG1C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information ifn d explain the nature of the of this record has bem provided to the well owner.
repair under f21 remarks section or on the,back of this form.
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 1 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
9.Total well depth below land surface: r6 r (ft.) I'
For multiple wells list all depths tf different(example=.3@200'and 2®100D Submit this GW-1 within 30 days of well completion per the following:
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
lfwater level is above casing,use ,
11.Borehole diameter: (in.) Bit Off: �� 3•, 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY c1
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le,auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci i P over 100,000 GPD:Copy to DWI,CCPCUA
13a.Yield(gpm)
�o Method of test: �'d�A/ Permit Program,1611 MSC,Rall igh,NC 27699-1611
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: 3� �A n