GW1-2022-03142_Well Construction - GW1_20220214

W+LLL'CO STiRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�Ci /r/L f�✓ �r/7 FYI 14.WATER ZONES
Wen Contractor Name ����, !�1"'�1V>1 EOM TO DESC i TION
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ft, ft,
NC Well Contractor Certification Number ftg 14 15.OUTER CASING forniniti-cased wells ORLRWER(Ifffaip licable
YADKIN WELL COMPANY,INC' M UfIX FRO TO DIAMETER TffiCKNESs MATERIAL
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Company Name �� ^ 3(6 V
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit 2-( FROM To DIAMmM TEaCKNESS MATERIAL C
List all applicable well construction permits(ie.Mr,County,State,Variance,etc.) 4 / ft ra ft in. uc,
3.Well Use(checkwell use): ft R in.
Water Supply Well: 17.SCREEN z
FROM TO DIAMETER SLOT SIZE THICtCYFSS MATERIAL
❑Agricultural ❑Munkipal/Public R, ft.
❑Geothermal(Heating/Cooling Supply) ❑p�Residential Water Supply(single) ft. ft.
❑Industrial/Commercial residential Water Supply(shared) 18.GROUT v
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERAAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
t. 3 ft. • s G��,,,.
❑Monitoring ❑Recovery 3 tt 3 ft' ,? v,✓ t./9
Injection Well: [....ft Caw..
❑Aquifer Recharge ❑Groundwater Remediation
I9.5AND/GRAVE(,PACK rf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EAIPLACEMENTN=oD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control it
❑Geothermal(Closed Loop) ❑Tracer 20.DRII,LIIVGLOG attach additional sheets necessaryl
FROM TO DESCRIPTION color,hardness,soVrvek in s' etc
❑Geothermal(Heating/CoolingRetu/m) ❑Other(explain undger�#21 Remarks) ft, er- fL SC,%r
4.Date Well(s)Completed: 1 'Z Z'We1lID#/4/-16 � c� �s IL Z Zv ft• Q ,
5a.Well Location: b Z Zv ft SD fL 1e4 G,• 'A
Phone #MC-�3a-61'��i
X - .1/Owner Name Pari]itttylIlfl(ifapplicable) ft & MM�
`G\9-1 Ye-LA it. ft �Y
�V A t fL
Y&
Physical Add/rasa, ,and Zip f
a Q
A k 21.REMARKS j
County Parcel Identification No.(PIN) do t , cew -i I^.
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /'e To
(ifwell field,one lat/loagiis/s sufficient) 22.Certification:
3 C u /<&* r� N c. .t /.
6.Is(are)the well(s): IRPermaneut or ❑Temporary Signature of Certified Well Contactor Date
By signing this form,I hereby certby that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or P�0 15ANC4C 02C.0/00 or 15A NCAC 02C.0200 Well Construction,Standards and that a copy
If this is a repair,fill out known well construction biformation 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 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remaria Box):You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS r.
9.Total well depth below land surface: /V,F- (ft)
For multiple wells list all depths fdiffwEnt(example-3@200'and2®1000 Submit this GW-1 within 30 days of well completion per the following: _
r
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), \
J ® �--
if water level is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter: On-) Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC) \
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.c.auger,rotary,cable,direct push,eta.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells product g over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of test: r�J(� pow e J-
13b.Disinfectiontype, 70%HTH Amount: 3y OZ DATE SITE VISITED: �2_� 'L� O ®ota.'a
VISITED BY: Melt?