GW1-2022-06449_Well Construction - GW1_20220411

t $�CONS UC)Tir N REC0RD dGW-_Q For Internal Use Only:
1,Well Contractor Information:
�_ r✓lv J,� ' 14.WATER ZONES
Well Contracto Name FROM TO DESCRIPTION
S 7 ft
NC Well Contactor Certification Number
APR 1 202_ A OUTERgrG for multi-cased wells ORLINER(-if RP licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THI0ams MATERIAL
ft ft in.
Company Name .: "•»_��
.�•: 16•ReM CASING OR TUBING 'eothermal closed-loo
2.Well Construction Permit#: h• )r P
/ r^,31 I� FROM TO DIAMETER TffiCIQVFSS T'LL
List all applicable well construction permits n e,LUC,County,Slate,Yarlance,etc) it , rya. /O V
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMErER SLOT SIZE TMCIG4ESS MATERIAL
❑Agricultural ❑M1IDlcipalRablic ft. ft. in. _
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) D in
❑Industrial/Commercial (❑_Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,006 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOIINT'
Non-Water Supply Well: D ft. q' ft per,L1�t;
o u re,C
❑Monitoring ❑Recovery q it
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remedistion
19.SAND/GRAVES.PACK da licable ('!
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E1%1P1ACCMENTMETHOD:,
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft �r
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necesszt" (61
❑Geothermal(Heating/CooUngRetm'n) ❑Other(explain under#21Remaik:s) FROM xo DFscaatYTlox miarearaness;:wvrnrlc :
-r9_ ft o,�- h'1 � w1 P-o�
A.Date Well(s)Completed:.ID - Well ��� Sq ft• ro95 /11Cr�' 4� �2' rk- t
5a.Well Location: Phone # 35 It 670 r�`-iliv7fe -3�/ C
�-t tl1�l �IRM+•Kt CA S(I sedgy C✓ I -ja rl�ed /y/ rcn
Faa ty/OwnerName Facilitymo(if e V ft. fL
�3G"Ao33 it. it
Physioal Address,City,and ZAP A*(AL?
(A ft ft
S/7 el l ZS.RAMARTCC ?
County Parcel Men$fication No.aw) C4 fl t7 4e4-?/ C� G« J(� O Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
gwell field,one lat/long is sufficient) 22.Certification: -r•J h+'P ja z Wks ago-a *X
PL,11`a9 R,edCS
N / Sl yS' W o
6.Is(are)the well(s): IXermanent or ❑Temporary S
,OPrure of C&fficd Well Contactor Date
By signing thisform,I hereby certify that the w ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 040 15ANCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a_riopy
1f this is a rgpa/r,fill out known well construction igformation and explain the nature of the of this record has been provided to the well owner.
repair under f21 remarks section 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'inRemarks Box).You may also attach additional pages if necessary. -
drilled: l 24.SUBS L&L INSTRUCTIONS
9.-Total well depth below land surface: (ft)
For multiple wells list all depths Ifdifferent(example-3@20t�d2©100) Submit this GW-1 within 30 days of well completion per the following:
j,
lo.Static water level below top of casing: 75"� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level Is above casing,use"+" Information Processing Unit,1617MSC.Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) Bit Off' /P'1 Y3 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(1UC)
Program 1636 MSC,Raleigb,NC 7699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open''-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,dirzct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing:over 100,000 GPD:Copy to DWI;,CCPCUA
Permit Program,1611 MSC,Raleigh,!NC27699-1611
13a.Yield(gpm)_ �y _ Method of test:
70%HTH ' g, OZVISITED:
13b.Disinfection type: Amount: / DATE SITE
Pri t-a• (SITED BY: �� �� �