GW1-2022-01801_Well Construction - GW1_20220214

y09#rCONS TRI( CTIION RI E COR D (GIV-111 For Internal Use Only:
I.Well Contracto lnforrmntion:
14.WATER ZONES --- — - -- ' ^
FROM TO DESCRIP,"I N _ v,
Well Contractor Name r' /
NC Well Contractor Certification Number 4 2n22 15,OUTER CASING for multi-rased weM OR LINER of a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETIe'IL TffiCENESs 114ATERIAL
7 FA It. f. in.
Company Name Mtsc.. '/ �373(y' .] 16.Il'WER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: SC2 FROM TO DIAMETER I TMCIINFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc) 4- ft15q G
ft ft. in. �l
3.Well Use(checkwell use):
Water Supply Well: El
17,SCREEN TO DIAMM-R SLOT SIZE THICIQYESS MATERL4L
❑Agricultural ❑Municipal/Public W;4_ ft. ft. in• ��-
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. ft, ir,•
❑Industrial/Commercial ❑Residential Water Supply(shared) 16.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATEIIIAL EMPLACEMENT METHOD&AM,/OUNT
Non-Water Supply Well: Q ft' Re.) ,,-1 v 4, 1 d;,,-el
❑Monitoring ❑Recovery ft 95
( ft-
Injection Well: ft. R
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Cif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAT, EMPLACEMENTMETHOD
❑,equifrr Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionil sheets if necessa C
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarles) FROM To DFSMUFTI N color,hardnm,soil/rock a ace,etc
'`g 0 ft. 1 ft S�.r r
4.Date Well(s)Completed: ! i (J� Well ID#H-f its Sa� 6 ft' • S ft' ,�Yl art fort
r _ fL "
Sa.Well Location: Phone #33G- 62-0-I 69' )
ft
r` V i t:t e b rVU'
�!r i /:�7 i .Sr i
Paci7ity/OwnerName Facility ID#(if applicable) ft i} /h Per SGt f r' "pA
2•tf-v �;���.�T � S/-'�w � r eft p�A rr. � i 00.� 4 L
T ft tt
Physical Address,City,and Zip _
��� 21.REMARKS _
Co n1y V Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lat/longis sufficient) 22.Certification:
2`Z, 2�1c5 N $�'` ®�. S 3`� w
6.Is(are)the wells) Permanent or ❑Temporary Signature of Certified Well Contractor Date
�,/� By slgning thisform,I hereby certify chat the well(s)was(were)constmcted In accordmrce with
7.Is this a repair to an erdsting well: ❑Yes or Belo 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. 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-1 ' 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: ��� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd fErenl(example-3@200'and 2®100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60, (ft.) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off:. ,5d 40 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) R
Program,1636 MSC,Raleigh,NC:27699-1636 C
12.Well construction method: AIR ROTARY 24c.For Water Supply and Own-Loop Geothermal Return Wells:Copy to the �
(Le.auger,rornry,cable,direct push,etc.) county environmental health departm pent of the county where installed +1
R
FOR WATER SUPPL WELLS ONLY: 24d.For Water Wells producin 7,over 100,000 GPD: Co to D�' J_ Copy WR,CCPCUA
f �'/ Permit Program,1611 MSC,Raleigh,NC 27699-1611 7C." 6 ts'sCd'<-
13a.Yjeld(gpm) Method of test: R
70%HTH c I OZ DATE SITE VISITED:
13b.Disinfection type: Amount:
G VISITED BY: