GW1-2022-05535_Well Construction - GW1_20220603

g I iT�1[JC I`Tp11-1 RECORD GW-1 Only:
1.well Contractor Information:
� i ��' s", [J �✓/� 14.WATER ZONES V xp s`0,
FROM I TO
Well Contiactor Name v •:i s >
3,0 U. �: v 7 I s f ' yso= Go-
NC Well Contactor Certification Number
15."OUTER CASING formu]fi-ee'sedrweDs ORLINF.R'if:a GcalilE
YADKIN WELL COMPANY,INC. FROM TO DIAMSfER THIlDOIEIis ?tMATERiAL
ft
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Company Name S"o,•j J —S"T3._ -V 3 16.neUR CASING ORTUBING iothermalelosed.loo-rus% or,
2.Well Construction Permit#:3 T 7 FROM TO DL*JWLr R TfficiOVFss G MATCRiAL
List all applicable well construction permits(Le.LIIC,County,State,Variance,etc-) R /3
3.Well Use(checkwell use): fl:
17.SCREEN
Water Supply Well: f
mom To DLkm='' sf oT smim aT>�CtarEss� MATF.RG►Li�i
❑Agricultural XSidential
icipal/Public ft.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. I
❑Iudustrial/Commercial 106dential Water Supply(shared) B.1 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM ft. TO� tti MATSMAL ngrnC�T'METHODP&7A►�►�►U,IIN�TI)
Non-Water Supply Well: J' 621k,.7�!'✓il
❑Monitoring ❑Recovery 3 R' �°U lain `a ` � •y 7��<
Injection Well:
❑Aquifer Recharge ❑Groundwater Remedistion
19.SAND/GRAVEI.PACK da livabl e) 11 d
❑Aquifer Storage and Recovery ❑Salinity Earner mom To _ ruTERtar. r ft ��ht�I%►CL>�NrMRrsoD��
r ,
❑Aquifer Test ❑Stormwater Drainage
❑Experiments]Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING:IAG'a"Hach addidiirial cheetf if neerssa..
FaoM Dss ON:cclostb
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Retnarks) x09 cRlpTtacaaess"'4:ovrnct�,
4.Date Well(s)Completed:) _—I Z WellID# ` �1`U R
51.Well Location: Phone #T J
zihm
S�10_ SEW 336-70k-3CM0 210 off.
Facility/Owner Name Facility ID#(if applicable)
QQ,p)� ` q A d .Q . it ft:
' k
Physical Address,City,and ft ft v x tl
.2L RFMAM' ly' '§
Co,my Parcel Identification No.(PIN) LAIN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: {l T1
(ifwellfield one laUloagis sufficient) 22.Certification:
q
Sigoainre of Certified Well Contractor
6.Is(are)the well(s): permanent or ❑Temporary r ' p. Date
!l
By stgnurg thisform l hereby cirtlfy trial the wdl(s)was we in rdmtce with
7•Is this a repair to an e)dsttng 1 well: ❑Yes or 9 15ANCAC 02C.0100 or 1�ANCACID2C 02001Pe11 Construction SYandards.and.lhat acopy .�
If this is a repalrr,fd/out known well construction blib mation 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 forms ' i
23.Site diagram or additional well detafls
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of s page to pso�v}do additional v/ell ronstrii info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
(add See Over'in Remarks Box)9'Ydu may `10. afonal;pages ifDecessary.
drilled: i s 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GVf1 within 36 days of well o- letion,per°the,following:
For multiple wells list all depths 1fdirerent(example-3@200'and 2@1001 n
/ 24a..For All Wells: Onginal'form to D v sr f Water Resources (DWR),
=,10.Static water level below top of casing: f� A) ��ticm proamsingU iit,16171&C,Ralergh,NC 27699-L617
Ifwater level is above casing,use
Bit Off: o 9aZ. 24b For Iniection Well's:Copy to DWR,,Undergro nd Injection Control @lUG)
11.Borehole diameter: (�) Progrffin;1636 MSC,Raleigh,NC'276994636 €
12.Well construction method: AIR ROTARY
24c,For Water Supply and Open Loori deotherm al,+Return Wells:Gopyto they
(i.e.auger,rotary,cable,direct push,etc.) county eaviromnental health department of the county where'mstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prod udng over 100,000 D.Co topDWR,GG'PCUA;
PY , �
Permit Program,1611 MSC,Raleigh,NC 27699-16l 1"r "
13a.Yield(gpm) U Method of test: t
70%HTH 3 C� Oz DATE SITE VISITED:
13b.Disinfection type: Amount:
f�
VISITED BY: &r%.