GW1-2022-06532_Well Construction - GW1_20220513

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.its , , a+&MILONt r �-11 For Internal Use Only-
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1.Well Contractor Hnfor lion:
14.WATER ZONES
ar�a FROM TO DESCRIPTION
Well •onhactnrName L p s� 9
!#�CY� '3 ft l ✓C ft a C�dyil
NC Well Coahaclnr CettiSeatiomN»bc 15.OUTER CASING for multi-rased wells ORLINER if a livable
YADKIN WELL C01111PANX,INC. FROM To DIAAnsrER THICI MESS MATERIAL
ft ft C !in.
CompanyNeme {� dLS =� *,r-7
16.INNER CASING OR TUBING eothermal closed-too
2.We11 ConBlilleti0n Kermit © 0 FROM TO D THICKNESS MATERIAL
1st all ap/lcable,wel!construction permits(t a illG,Coun ,State,Variance,eta) ft. ✓ ft in. o [ dr J,
3.Well Use(cbeckwell use):
Wat r SupplY W ell: rnOM�E TO DIAMETER SLOT SIZE THICtavEss MATERIAL
OAg<ac ]tma] llMtmioipal/Public ft. in.
OGeo enmal(Heating/CooIing,Supply) sidentiMi Water Supply(single) ft. I ft. I in.
OIndustriallCommercim Rrsidesltial taster Supply(shared) 18.GROUT
O on G1Wells>100 000 GPD FROM TO MATERIAL EMPLACEMENT ATETSOD&AMOUNT
N n Wa`t�e"F"�Supply Well: 011 31, N ,
OMnnitorang t]Recoyery3 it 7,"( ft' �J f vt N►
Injection Welt•
ft. ft
OAquiferRecharge OGround aterRemediaton
4 : 19.SANDIGRAVEL PACK Cif a lirable)
OAgtrifer Storage and Recovery OSaliaity Beerier F:. FROM TO MATERIAL EMPLACEMENTM=01L
O uifer Test OStormwater Drainage R f
OI�cperlmental Technology OSubsidence Control ft ft
O ermal(Closed,LOop) UTracer 20.DRILLINGLOG attach additional sheets ifnecessa
C] eirl]fll C C00 l> nn 0�1W ex lain under#21 Remadcs FROM TO DESCRIPTIft, ji ON color,hardness,soilfmcktypr,umn sae,etc
4.Date Wells)Comple d: 4 �` ..d 3 o fi g j4 t.hell
5a ellLoeatioa: 21'�d ���� ft u. ft
c
u ft. lur_ 'L ,7t, r, d
Fe~mlity/OwaerName FacyID#(ifapplicable) ft ft
ft. ft
i� Il/Q m
Physioel Address,C$y,and Tip ft ft.
4 2L REWL4RKS MAY
Gamty Parcel+Identification No.(PIN) v
5b.Lati a and longitude in degreeshnin tes/seconds.or decimal degrees: W* n PT Unit
(ifwell+field,one IMMM4oagis eat) 22.Certification:
6.Ils(are)the well(s): ermanent or Temporary Signature of tlerEW Well ntnctor Date
By signing this farm,l hereby certify that the well(s)was(e+ere)constructed in accordance with
7.L this a repair to ea e�dsting well: Oyes or L�lPio I5ANCAC 02C.0100 or l A NCAC 02C.0200 Well Construction Standards and that a copy
If ibis is a repair.,fdl oul-btoxm well conshveHan fry/otmallon and erp/oin the nature of the of this record has been provided tothe Hell owner.
repofrimder$27 remarlorsectton or on the:back ofihisform.
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
eoushuchion, ER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
arnica. / 24.SUBMITTAL INSTRUCTIONS U
9.Total well depth below land surface:
e 2Q100� A) Submit this GW-1 within 30 days of well completion per the following:
Form iIplwellsHsfa depts fdl�jerent,(erample-3(�It)0 nd t 4
24s. For All Wells: Original farm to Division of Water Resources (DWR), Y
10.Static water levkl bet top of casing: (f'� `4 (ft.) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
if or levells ab
Bit,Off: '7 yJ� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diamete (�) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction ethod: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i e.sugar,rotary,cable,direot;pusb,ata!) county environmental health department of the county where installed
FOR WATER SY WUNL�Y: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method oftestc'/'
OZ DATE SITE VISITED:
136.Disinfection type= Amount• ��y�
VISITED BY:
Form:GW t1 North Cazolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018