GW1-2022-06601_Well Construction - GW1_20220711

WELL LL CONSTRUCTION[RECORD (G'W-i11 For Internal Use Only:
1.Well Contractor lnformntion:
A4 Z_& / &I"PI 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft-
WC Well Contractor Certification Number 15.OUTER CASIIKG for multi-cased wells ORL_ if a livable
YADKIN WELL COMPANY,INC. FROM To DIA141IITER CsarEss MATERIAL
Company Name w.
16.INNER CASING OR TUBING eothermal dosed loo11
2.Well Construction Permit#: w—1 —1(P FROM To D7�14T TER I Tmcx rss I ivrATMUT,
List all applicable well construction permits(f,e.i7IC,County,State,Parlance,eta) ft / ft. 16,1
in. siep.
_ ,' Rmc
3.Well Use(ebeckwell use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICIMSS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it ft.
❑IndustdaVCommerc;W - ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO DfATERIAL EMPLACEMENTMETEOD&AMOUNT
Non-WaterSupplyWell: ft. IL
❑Monitoring ❑Recovery 3 ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation I9 SAND/GRAVEL PACK Cxf a lirable
❑Aquifer Storage and Recovery ❑SslinityBarrier FROM TO MATERIAL I EMPLACrMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft:
❑Experimental Technology ❑Subsidence Control it
[]Geothermal(Closed Loop) ❑Tracer T ;J . 20.DRILIMG LOG attach additional sheets if necessary)
❑Geothermal(igeating/CoolingRetu¢n) ❑Other(explain under#21Remarks) FROM To DESCRIPTION wlar,b,r-duen,:oivrnex . sim,ete.
a.Date wel(s)Completed: 7"zt Well ID# Mi-ft .2 ed ft
Sa.)We-alllocation: Phone # 7Oe/- �ApZ'6�/J,g 11 36 fL ®� ° _
/aL T �i.✓ ��a /sie B^ y :0: ft. ft� eI -
Facr7ity/OwacrName Facility M#(ifapplicable) ��r�t `` `�
r
�? 7 8�,m r 'Ile^ N�y]C fly` 4yty..z gNN
Mysicil Add=s.y,an V Y� irt:1 ." �WP p AA 21.REMARKS
County Parcel Identification No.(PIN) L 1.1 2n29
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1:4 I I�lr
(ifwell field,one lat/longis sufficient) 22.Certification: PROCESSING Uf�IIT
6.Is(are)the well(s):,*ermaneut or ❑Temporary Signature of Certified Well Contractor " Date
By signing thtsform,I hereby certify thai the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I0 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If ibis is a repair,fdl out known well construction b1formation and erplain 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 form.
23,Site diagram or additional well details:
S.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 Remarim Box).You may also attach additional pages if necessary.
drilled: 24.SUBM1•TI'AL INSTRUCTIONS
9.Total well depth below land surface: A) Submit this GW-1 within 30 days;of well completion per the following:
For multiple wells list all depths lfdifferent(emmple-3(a)200'and 2Q700D
_ (ft 24a. For All Wells: Original fnrin to Division of Water Resources (DWR),
10.Static water level below top of easing: �e) ) Information Processing Unit,I617 MSC,Raleigh,NC 27699-1617
er level Is above casing,use
If waf
Il.Borehole diameter: Sit Off:��7 , q 24b.For Infection Wells: Copy to DWI,
,,Underground Injection Control(IUC)
�/ (in.)
Program,1636 MSC,Raleigh,NC 27699-163 fi
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-)Loop Geothermal Return Wells:Copy to the
(Le.auger.rotary,cable,direct push,etc.) county environmental health departrnIent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR'CCPCUA
13s.Yield(gpm) 14 `12. Method of test: /`1 41,f PennHPrognml,1611 MSC,Raleigh,NC 27699-16I1
i
13b.Disinfection type: 700/o 6 DATE SITE VISITED:HTH Amount: 4� OZ