GW1-2022-03399_Well Construction - GW1_20220315

Y, tL+CtONSTRUt TION RECORD LEE-�W For Interne].Use Only: �
1.Well Contractor Informntion:
14.WATER ZONES
Well Contractor Nam FROM TO I DESCRIPTION
�s 7a &35'ft• OF ft
ft. ft 4
NC Well Contractor Certification Number IS.OUTER CASING for multi-rased wells OR LINER if a livable
YADKIN WELL COMPANY,INC. FROM xo DIAMETER TEIt�tEss MATERIAL.
ft ft in.
Company Name
W 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: s FROM TO DIAMETER TEICra ms MATERIAL
tillLisa all applicable well construction permits(i a CIiC,County,Slate Variance,etc) 4lsr ft ps,k of in' ✓C.
ft
3.Well Use(ebeckwell use): fr' in.
17.SCREEN I
Water Supply Well: "
FROM TO DIAMETER I SLAT SIZE TEICIQVESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑IndustdaUCommercialidentisl Water Supply(shared) 18.GROUT fi
❑ui lion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT AM-THOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery it ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da lirnble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENTMETEOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Trager 2U.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remiulcs) FROM TO DESCRIPTION color,hardnw,soVracxft q Am sae eta
63L 702 17hnl � a
4.Date Well(s)Completed: �2 Well m#(T!`T Q` 3 t} -
ty ft ft 1�1i ►
5a.Well Location: Phone # �3�-/�1-1n o8Q
ft ft
Faoilityy/OOwnerName L / /F�acilityID#(ifopplieable) ft ft
(t 3 3 ir-�c(/'fla t 727n I t'�f: • �r ft ft
Physical Address,City,and Zip ft ft VT.mIV,gin
ev.`llTcr 21.RE oc✓ r•;III �197
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
Fe3r N Z .2-54l3 W
6.Is(are)the well(s):Wrmanent or ❑Temporary _ S' of ---d Well Contractor Date
`. By signing thisfarm,1hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: rdYes or 0 6,e�0 G Yt 15A NCAC 02C.0100 or l A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,ftl/our known well construction information and lain the na}ure of the ofthis 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: J 24.SUBM ICTAI.INSTRUCTIONS
9.Total well depth below land surface: 709a f (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(emmple-3Q200'and 2®1000
a� ? 24a. For All Wells: Original form to Division of Water Resources (DWR),
ft
10.Static water level below top of casing: ( ) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" ,/ 7� z
11.Borehole diameter: jD (in,) Bit Off: F� 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC) e
Program,1636 MSC,Raleigh NC 27699-1636
AIR ROTARY
12.WeIl 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 G
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
5 Method of test: to V t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
70%HTH � C OZ DATE SITE VISITED: !I L 2, -D
13b.Disinfection type: Amount: • 1 `2
ytj
! �44*61ITED BY: tq i N
P r 7("P' � i S iAL/��i/Ll "�
r:�rm rW-1 North Carolina Dep ent ofEuvucTnmental uality-Division of Water Resources Revised 6-6-2018