GW1-2022-03515_Well Construction - GW1_20220316

MW ONS RIUC aTIQN RECORD (GV—V-1) For Internal Use Only:
1.Well Contractor Information:
J OGL �J �S 14.WATER ZONES
Well Contractor a FROM TO DESC T10N r '
ft. ,SO
ft
NC Well Contractor Certification Number 15,OUTER CASING for aiulfi-rased wills OR LIPiER �f a linable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TffiC[OYESS MATERIAL C
in.
Company Name 16.INNER CASING ORTi16ING eothermalclosed-loo )
tr S
2.Well Consull EE
ction Permit#: bV-5 M 6z "0o3�QA +�2 ( FROM TO DIAMETER THICIQ4FS5 I MATERML
List all applicable well construction permits(ie.XC,County,State,FEriance,eta) 41 R It l-A O in' '1 0"T (V
3.Well Use(check well use): ft. R' in. T—
Water Supply Well: 17.SCREEN rT
FROM TO DIAMETER SLOT SIZE THICfINES5 MATERIAL
❑Agricultural 2sidential
unicipal/Public n, ft. in.
❑Geothermal(lieating/Cooling Supply) Water Supply(single) ft, ft. in.
❑Iudustrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
❑In-i ation ❑Wells>100,000 GPD FROM To MATERrAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: <r. ft. ft. 9,0 -dt o t(ej
❑Manitcring ❑Recovery % it �� ft•
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation fr. ft.
19.SAND/GRAVEL PACK rf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EM*1PLACEM ENTM=OD
❑Aquifer Test ❑Stormwater Drainage ft ft C
OExperimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retom) OOther(explain under#21 Remarks) FROMI TO DFSCRn nON color,hardness,so9vrvcic e arnin ske,etc
o ft ft so.L
' s •4.Date Well(s)Com_ pleted: ��$-a� Well ID# ft 0 ft OG k fA
A^ VA
Sa.WellLocafion: Phone # (& W- ® ( O fL 9 It 4'1d cjoiL- Wt
72 ft aka-' ft. a� 'OL!�
Fac�7ity/0 erName FacilityID#(ifapplica�le) ft ft
.Z� �� ��•�—mil tag°1/� �c� t�r.�il�•�E�olcs�l���:,� ,ems,`�;, 'r" , _..
Physic t
Physical Address,City,and Zap 7 0 f ft
Q/ */' 21.R_EAIARKs MAR 6
County - PmT4 Identification No.(PION)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latlloagis sufficient)
22.Certification:
N ®O" 7, W _
6.Is(are)the well(s): Sxrmanent or ❑Temporary Sig11aWCcr4&WdI Contractor Date
By signing thisform,l hereby cer*that the wells)was(were)constructed in accordance with A
7.Is this a repair to an existing well: ❑Yes or a0 1 SANCAC 02C.0100 or NSA NCAC 02C.0200 Well Construction&andar*and that a copy
If this is a repalr,fdl out known well construction information and explain the nature of the. of this record has beenprovided to the well owner. d
repair under#21 remarks section or on the back of this form. P
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 Remado Box).You may also attach additional pages if necessary.
drilled: I ? 24.SUBMITTAL;INSTRUCTIONS
9.Total well depth below land surface: 'wa Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(example-3@200'and 2®100)
10.Static water level below top of casing: y0• (ft-) 24a. For All Wells: Original form to Division of Water Resources (DWR),]fwoler level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Bit Off' 16.05 D 24b.For Infection Wells: Copy to DWR,Underground Injection Control(lUQ
Program,1636 MSC,Raleigh,NC 27699-1636 V
12.Well construction method: AIR ROTARY \
24c.For Water Supply and Open-Loop GeotbermaI Return Wells: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 producin(iR over 100,000 GPD: Copy to DWR,CCPCUA R
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 C9 Method of test: Q qd 9
13b.Disinfection type: 70%HTH Amount: 7. / OZ DATE SITE VISITED:
_-- VISITED BY: