GW1-2022-01773_Well Construction - GW1_20220214

5 ` CONSTRUCTION RE CORD (GVV-I) For Internal Use Only:
I.Well Contractor Information:
A/�! 1 l � al n e��/2 14.WATER ZONES
-J FROM TO D>SCRIPTION
Well Contractor Name
NC Wen Cotea rCertificationNmnber 1 \IEC E I Y
YADKIN WELL COMPANY,INC. CD 1 4 2��)
in. KCompany Name S �<< �/G y l
n PrxNowp Ur"Il 16.IN NER CASING OR TUBING eathermai ed-loop)
2.Well Construction Permit#:- '3/eA` °`�' non FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits re.UIC,County,State,Variance,etc.) ft 6 ft 1 P257 in. S -
3.Well Use(check well use): R• fr in.
IzItk
Water Supply Well: 17.SCREEN ` r,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipa]/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. Q
❑Industiial/Commercial ❑Residential Water Supply(shared) I8.GROUT M
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft L
❑Monitoring ❑Recovery it ��
Injection Welt: ft ft
❑Aquifer Recharge []Groundwater Remediation
I9.SAND/GRAVEL PACK(if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. R-
❑Experimental Technology ❑Subsidence Control ft ft d
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa t
ordam
❑Geothermal(lleating/CoolingRetum) ❑Other(explain under#21 R�ejmarks) 0 ft. ft 0 , .
FROM TO DESCRIPTION color,h soiVrock e, sae,att.)
4.Date Well(s)Completed: - -1 Well ID# 46—f 3 �y R- C� fi- a 1r �� . 'e, t fe �►
'Sa well Location �� Phone # 3���/q-�$y `.-( /�' /'".-A
)i'`y�'l G 1^D�t_�^ /lllXillL W —G 103 it 1 I G
Facility/OwwneerrNaame b / Facility ID#(if applicable)�1 (j'2® ft 1 1 3 H L.�,I m% - We f't
7 ! w, !�to w4k, FE df l►�'�,�� cif I 1-3 R ?9` � on-e :: o•1;,t j z \\\=�"
Physical Addmss,City,and Zip T i� s-1 ft 1(! C I.:✓n
21.REMARKS t
County a a ` Parcel Identification No.(PIN) I 1i� �1*� /+%t e ls'•,%I ram'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification: r)
7 N �f f o 7�. At'Cs`Ay W
6.Is(are)the w'ell(s): Oermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby ceri#y that the well(s)was(were)constructed in accordance with V
7.Is this a repair to an existing well: ❑Yes or tkqo 1 SA NCAC 02C.0100 or l5 4 NCAC O2C.0200 Well Construction Standards and that a ropy W
If this is a repair,fill oui known well conshvction information and explain the nature of the of this record has been provlded to the well owner. ]�
repair under$21 remarks section or on the back of this form. 0 `
23.Site diagram or additional well details:
S.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-1 is�}eeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages Ynececsary,
drilled: LL *30 ` 24.SUBMITTAL IN TI STRUCONS
9.Total well depth below land surface: J v (ft)
For multiple wells list all depths If different(example-3 r©200'andd 2®100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ` 15 \ (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Bit Off: , 1 24b.For 1giection Wells: Copy to DWI;,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY t
12.Well construction method: 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 DW)2,CCPCUA t�
m 13a.Yield
(gP ) Method of test: �C!/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
�^
13b.Disinfection type: 70%HTH Amount: 1' OZ DATE SITE VISITED:_ 6 �( �.►1 j ��a1
d— i.1 men t r 1
� VISITED BY: �B