GW1-2022-06490_Well Construction - GW1_20220603

LF� C&S' JllL ' 1Ut"J", ON RJECOR D(GW-1) For Internal Use Only:
1.Well Contractor Infornantion:
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L✓i/ 14.WATER ZONES
Well Contractor Name FROM TO =SCRUTION 7 1
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NC Well Contractor Certification Number
15.OUTER ASING for multi-cased wells ORLINER of a livable
YADKIN WELL COMPANY,INC. FROM I TO L0=T;xR TffiCEIVESS MATERL L
Company Name JC,.ku.Z-Z' t?T d 7-CI-® 3 f � in
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16.INNER CASTING OR TUBING 'eothernial closed-loop)
2.Well Construction Permit#: G't FROM TO DIAMTER Tmmam nATERIAL
List all applicable well construction permits(Le.WC,County,State,Yartance,e[a) 41 ft3/ ft � I/ in. Ji1 lQ-� / llG
3.Well Use(check well use): R 1II' UU,` /
17.SCREEN
Water Supply Well:
FROM TO DIAMETER I SLOT STLE THICIMSS MATERIAL
❑Agricultural ❑Mimicipal/Public ft. - in.
❑Geothermal(Heating/Cooling Supply) 96sidential Water Supply(single) f ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑InigatiOn ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT I
Non-Water Supply Well: ft' 3 ft' 6oi�g y ,�,v' 3�L
❑Monitoring ❑Recovery 3 tt .1 v
Injection Well: fi 7�
❑Aquifer Recharge ❑Groundwater Remediation Id Z Z % &4 6 raw,5
19.SAND/GRAVEL PACK da livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimenta]Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
❑Geothermal(Heating/CooHng Retum) ❑Other(explain under#21 Remarks) FROM fL I To DESCRPTION color,hudaess:oVrnek • cvs,etc
4.Date Wells)Completed: -CD-ZZ WellM# s ® ft CjrG.s/�v
5a.Well Location: ft &
Phone #7o�.- 322-22 °7
Fae,3ty/OwncrName Facility ID#(if applicable) ft f
fr P%�✓"/A wG R;OVA
ft. ft
Physical Address,City,and - ft- t• P Kam,. .. ,
z1.REMARSS --.-P
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county Parcel Identification No.MN) JUN 0 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,.
(ifwell field,one lat/long is sufficient) 22.Certification: �117777 �f'{; I l�1ia
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6.Ls(are)the well(s): fe rmanent or ❑Temporary Signature of Certified Well Contractor Date
�� By signing Aisform,I hereby cer*that the well(s)was(were)constructed in accordance with
41n 7.Is this a repair to an odsting well: ❑Yes or o 15A NCAC 02C.0100 or I5A NCAC'02C.0200 Well Construction Standards and that a copy.
If this is a repair,fdl out known well construcion i>>/ormation and erplain the nature of the ofihfs record has been provided to the well owner.
repair carder#21 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 OW-1 is needed, Indicate TOTAL NUMBER of wells (add See Over'in Remarics Box).,You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface: J (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdnffereni(ixzunple-3 n()200'and 2®1001
10.Static water level below tap of casing:__ 6 Q 24s. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level!s above casing,use"+" (ft) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (�,) Bit Off: S, 2 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11 Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le,auger,mtary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci f tr'oyer 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: A a/s Permit Program,1611 MSC,Ralppeigh,N/C�27699-1611 A 1`,
13b.Disinfection type: 70%HTH Amount: 3 G OZ DATE SITE VISITED:J-`16- C.Z �e� v q 13
VISITED BY:
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