GW1-2022-06437_Well Construction - GW1_20220513

q RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: U
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14.WATER 20NES •
Well Contractor*me FROM To DESCRIPTION Q
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fr. ft
NC Well Contractor Certification Number �
1S.OUTER CASING for multi-rased wells OR LINER if a linable YADKIN WELL COMPANY,INC. FROM To DrAMaTFJc Tr3rcl�vEss MATERIAL
CompaayName14\CYliota-1ce- 3 X .a�� �3 ftR' in.
16.INNER CASING OR TUBING eothermal Closed-loop)2.Well Construction Permit#: FROM To n
List all applicable well construction permus(ae UIC,Covn State,Yorion )/ IAA2UrER THICItIVE58 ri4ATERIAL
tY re,etc) `�! fr / in. M t! q O
3.Well Use(check well use): ft, fr in.
Water Supply Well: 17.SCREEN
❑Agtiaultural FROM TO DIAMETER SLOT SIZE TMCKMSS MATERIAL
❑�Icipal/Public
[]Geothermalothermal(Heating/Cooling Supply) CdResidential Water Supply(single) ft.
in.
❑IndustriaU m Comercial ❑Residential Water Supply(shared) ft ft.
❑Iitj ation 19.GROUT
g ❑Wells>100,ODO GPD PROM TO MATERIAL EMPLACEMBH 1 METHOD&AMOUNT
Non-Water Supply Well: ft
r
❑Monitorin rCQ
g ❑Recovery IL ��, fr.
Injection Well: 3 J lt;,^fJ �
❑Aquifer Recharge ❑Groundwater Remediation ft
❑Aquifer Storage and Recovery ❑SSlmit 19.SAND/GRAVEL PACK rf a licable)
yBaiIler FROM TO MATERUIL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft
it.
❑Geothesmal(Closed Loop) ❑Tracer 20.DRILLTG LOG attach additional sheets if neeessa
❑Geothermal(Heating/CooIing Retum) ❑Other(explain under#21 Remarks) FROM To DESCSLIPTIOx color,hard/n�ess,soliroek nia:�etc
ffi ' fr. 0 GIB L✓eq T�PrI�
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4.Date Well(s)Completed:12— ellID# �'ft• ��', ' ft
Sa Well Location: - ft-
Phone
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ray
Facility/Owner Name
� �p) �y, Facility IDll(if applicable) � ft
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ft
Physical Address,City,and Zip ft ftWin
t3'I�nd✓sr1E_• �.. 21.REMARKS
County Parcel Identification
5b.Latitude and longitude in degrees/mknutes/secands or decimal degrees:
'(ifwell field,one lat/IOngis sufficient) 22.Certification: (`�\
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6.Is(are)the well(s): [Permanent or ❑Temporary Si of ed Well Contractor Date
By signing thisform,1hereby certj)�that the well(s)was(werel constructed In accordance with
7.Is this a repair to an existing well: ❑Yes of & 1 ISA NCAC 02C.0100 or 15A NCAC 02C.02001Pell Construction Standards and that a co If py
this is a repair,fdl out known well construction information and erp/ain the nature of the of this record has been provided to the well owner.
repair under#2I remarks secitan 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 GW 1 is needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary,
drilled: /
/; 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( )
For multiple wells list all depths ifdifferent(example-3@200''annd 2@100) Submit this GW-1 within 30 days of well completion per the following: 1
10:Static water level below top of casing: 7 0, (ft)
?�a• For All Wells: Original form to Division of Water Resources (DWR),
If water level Is above casing,use"+" Infoimation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) Bit Off: �-102 24b.For Injection Wells: Co to DWR,
Copy WR,Underground Injection Control(IUC)
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: j
(i.e.auger,rotary,cable,direct push,etc) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over IO 000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 7 S Method of tesf: pt ft Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70°/a HTH Amount: 1•7 OZ DATE SITE VISITED: '