GW1-2022-01043_Well Construction - GW1_20220107

3� I��lT UC 1TION RECORD (GW-1) For Internal Use Only:. 3
1.Well Contractor Information: :
_Allu 14.WATER ZONES r �
Well Contractor Nam FROM TO DRSCRIPTION "-
bI
ft.
NC Well Contractor Certification Number
15.OUTERCASZKG for multi-css'' eDs. LWER'�f:a bratile ex
YADKIN WELL COMPANY,INC. FROM TO' DIAMETER' THICMNESS--S MATE1rrAI,hr a O;
Cam an Name ft. L it
P y V/�� �3'p°� T�r,,qqV 9 `°Z q6 S ,��r d 16.INNER CAMG OR TUBING eotLermal closed Ioo"
2.Well Construction Permit#:.Iqs m lz A a d 3 06 2,6�g PROM TO DIA[YIETER :TffiCIOVFSs: ITSATER7ALs��� * �
List all applicable well construction prmeits(ire_IUC,County,State,Variance,etc) �n• t ( / s t
5
3.Well Use(checkwell use): ft., 'n'
Water Supply Well: 17.SCREEN.".
FROM TO DIAMETER '• SLOT SIZE w wT1110ams Ill TERIALIM
❑Agricultural ❑Municipal/Public ft. ft. in. a '�
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ui. VI
❑IndusttiaUCommercial ❑Residential Water Supply(shared) Ill.GROUT Y
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EhIPLACEMENT,NlETHODWIAMOUNTIA llC
Non-Water Supply Well: ft. ft ^k�
❑Monitoring ❑Recovery
Injection Well: ffi ft t
❑Aquifer Recharge ❑Groundwater Remediation "r
19.SAND/GRAVEL PACK"(if a llcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL M U?I:ACErdENT,MET3OD
$ ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. it
❑Geothermal(Closed Loop) ❑Tracer J20.DRMLINGLOG attach addrtio`tial sheWlf:aeeessa
FROM TO I)1SCRnM=Ncolor.`tiaidaee` s�oiVroefc `i'"icxQ"fct�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)'
ft. ftAN
4.Date Well(s)Completed: WeIIID# �' ft fJ ficsd pX11
Sa.Well Location- Phone # X
Facility/Owner ame Facility M#(tf applicable) ft ft. AW'k,� ;
I rfsek&t
Physical Address,City,and ZipXCI X0,5 -
County Parcel Men tification No.•(P'IM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hMongis sufficient) 22.Cerio9eationt`
6.1s(are)the well(s): N(ermauent or ❑Temporary' 6 5 e of G ed Well Ui6tori,
� / IF
Byslgning th/storm,I herby certify that the wells)w s(were),connsd cted In accordance with
wad
7.Is this a repair to an existing well: Dyes or �Io 15A NCAC 02C.6106 or/SA NCAC d2C 0200.IPel1 Constructron EYandords and thal a copy
if this u a repair,fill out known well construction'information and erplain the nature of the of this retard has been provided to the',-well owner
repair under#21 remarks section or on the back of this form. x
23.Site diagram'or additional well details •
You may use the back of this page to provide addtional well coDshuction"iafo
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same gw ,.
construction,only 1 GW-1 is needed. Indicate TOTAL NUNMER of wells (add See Over'in'Remadcs Box).You may also attach additional pages necessary.
drilled: 24.SUBN=AI;INSTRUCTIONS
9.Total well depth below land surface: q� (ft)
For multiple wells list oI!d 1hs i di Brent(example-3 00'and 2 100 Submit this GW-1 rvithin30 days of well completion per the following:- r
P eP f ff ( P @2 7 i
1D.Static water level below top of casing: e7 d (ft.) 24a. For All Wells: Original form to Division of.Wate ."'p, ources•(DWR),
I10.Stawater tic
is above casing,use op Information Processing Unit,1617 MSC,Raleigh NC 27699 1617
11.Borehole diameter: (in.)
Bit Off: % 937 24b.For Infection Wells:Copyto;DWR,Undergrd" Injection Co trol(IUC)
� � g�
Program,1636 MSC;Raleigh,NC,27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return-W-O Capy`�te the
(Lt.auger,rotary,cable,direct push etc.) countyenvironmental health department of the coup whale installed
P fit, *�
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells p% cing over 100,000 GPD:Copy to DWR,CCPC Air
d Method of test Permit Program,1611 MSC Raleigh,NC 27699-I611 .
13a.Yield(gpm)
70°/ HTH OZ DATE SITE VISITED
13b.Disinfection type' o (� i=�o x,, r
e Amount. . :. � �:
VISITED BY: