GW1-2022-03413_Well Construction - GW1_20220315

NYI LL,'+CONST1 'TXTION RECORD For Internal Use Only:
I.Wei;Contractor Informstion:
In/ti 14.WATER ZONES. i.
FROM TO DESCRIPTION
Well Contractor Name ,Q 9��
0 3 G A o it. r � ft. G++ i o� 0' I e,^ p v
ICY
NO Well Contactor Certification Number 230 ft V it d 0 360 a 361 ZV
15.OUTER CASING for multi-rasdd wells)ORLINF.R rf a livable
YADKIN WELL COMPANY,INC. FROM To DrAtrDtrER TfficalaEss MAI&L1, 1
Company Name ft J f� ft. r 2 3�, in. �,�f ry
16.INNER CASING OR TUBBING eothermal closed--loo /
2.Well CORStrnetiamPermlt#: FROM TO DIAMETER THICIUMS MATERIAL
List all applicable well construction permits(Ia.WC,County,State,Variance,e[a) it 9 ft m. / `Z©
`c� G!+ `Z (.9
> 3.Well Use(check well use): E ft' m. Cr
Water Supply Well: 17.SCREE,
FROM TO DIAMETER SLOT SIZE THIO ESS MATERIAL
OAgricultural 8Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑lndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non;WaterSupplyWell: G it. ® ft. A4.4 T^•,../,L
❑N iull`.oring ❑Recovery t tj" it ft.
lnjkedon Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rsf a livable)
❑Aquifer Storage and Recovery ❑salinity Barrier FROM TO MATERIAL LACEMENTMETHOD �
❑Aquifer Test ❑Stormwater Drainage ft. it.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 2 . RII LING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I To DESCRIPTION color,hardness,soil/mck type,Lrado sae.&L
0 ft. 10 ft.
4.Date W (s)Completed: /0-7,1 Well ID# -7 ft' -1< j'
v At+l *'o.n t r ft ft
5 .Welly cm :. l Phone #3 q- 'JV7L hCr go
L Jeve
ft. 2,0 IL
Facility/Owner Name FacilityM#(if applicable) 3 2-a ft 2 ft "-
a` Y �ur+ gam;Ili St- G sb ft MAR 1
Physical Address,City,and Zip ft ft' va
Ff .:_,
�'� -.�.�, »'
County Parcel IdenecationNo.(PIIN) L I'T't[ �4 `f "t
5bi Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if wail field,one latllongis sufficient) 22.Certification
6.Is(are)the well(s): 'afermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 90 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Will Construction Standards and that a copy
If this is a repair,fill but known well construction information and erplain 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 yell 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths if different(example-3@200'and 2©100� Submit this GW-1 within 30 days of well completion per the following:
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"+" 't
11,Borehole diameter: (in.) Bit Off:1�/Q 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY � M vd /`� �
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.s•aus7er,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciu`g over 100,000 GPD: Copy to DWR,CCPCUA
try�
Permit Program,1611 MSC,Raleigh,NC 27699-16I1
13a.Yield(gpm) Zoo Method oftest:
13b.Disinfection type: 70%HTH Amount: �2 OZ DATE SITE VISITED: 6
Dr i rP- VISITED BY: Z Z ,c
0.11 / I'M