GW1-2022-03405_Well Construction - GW1_20220315

v .00;L ONS 1RUC TI+ON RECORD (GW' -i11 For Internal Use Only: CD
1.Well ontraacttoorr Informntion:
,� 1O t q T T�' 0", in 0 6J A 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number � j G ft. �� ft
15.OUTER CASING for multi-cased wells)OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICIM MATERIAL
ft. I in.
Company Name r ✓ �I f4. �• �� C�� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 2-ozi o-7 FROM TO DIANILTER TffiCIINFSs MATERIAL
List all applicable well construction permits(i a.WC,County,State,Parlance,eta) ft `J V ft b 'A d P(/C
3.Well Use(check well use):
Water Supply i Well: 17.5CREEN
FItOAS TO DIAMETER SLOT SIZE THICKNESS pgA•rsnIer.
❑Agricultural ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) 9esidential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation []Wells>100,000 GPD FROM TO MATERI" EMPLACEMENT METHOD&AM
O
UNT
Plan-Water Supply Well: it 1 ft. 1�4
❑Menitoring ❑Recovery ft ft. , r
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.5AND/GRAVEL PACK if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Eri1PLACEMENTN=01)
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessaryl
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM To DESCREMON valor hardness,roiVratktyps grain sae etc
n I ®0 ft ft. i Sa� �6�LQi
4.Date Well(s)Completed: .0-`4-2 Z Well ID# ip It. g 6Z ft-
5a.Well Location:I�a��1 ft ft.
Phone #� -4 I �-•9V®r ft ft
P.
Facilitty/Owner Name Fa/ci*ID#(if spplieabjle) ft. ft��rr
Physical Address,City,and Zip i270 rO ft ft ! T7. r
21.REMARKR
County Parcel Identification No.(PIN)
SL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/tongis sufficient) 22.Certification: ry P
• W .q-
6.Is(are)the well(s): dermaneut or ❑Temporary Signature of Certified W&I Contractor Date
By signing thisform,I hereby rert ify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )<qo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and erplafn the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or an 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 i OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifelfferent(erample-3@200'and 2@100D
�� .) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
Bit Off: .�� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (th) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return WeIIs: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 producink over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method oftest: ��St( our
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
i
VISITED BY: