GW1-2022-06607_Well Construction - GW1_20220711

—WrLL+CO S 1 RUCTION RECORD _QW-1$ For Interrial Use Only:
1.Well Contractor Informntlon: I
14.WATER ZONES {
Well Contractor Name
FROM TO I DrsCRIP,TIUN
23S 224
NC Well Contractor Certification Number
15.OUTER CASING for multi-rased vveDs)OR LINER if a livable
YADKIN WELL COMPANY,INC. FROM xo DIAMETER THICIt?VE55 MATERIAL
in.
Company Name 16.nqM CASING OR TUBING 'eothermal Closed-moo
2.Well Construction Permit#:_ / �l�® FROM TO DIAMETER THICIOVEss I MATERIat
List all applicable we11 construction permits(be.UIC,County,State,Variance,etc) 4y& 14e ft /J �lc-g in-
` a
3.Well Use(ebrekwell use): % ft. G, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMOG E55 I MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) gesidential Water Supply(single) ft. !t. in.
❑Industrlal/Commercial ❑Residential Water Supply(shared) 18.GROUT
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' 3 1". 1401C 1pltr, P0e1W
❑Monitoring ❑Recovery it ;tS ft. rlf
ck
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(rf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology OSubsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets if necessary)
❑Geothermal(HeatinglCoolingRetum) ❑Other(explain under#21Remazics) FROM TO DESCRIPTION color,hardness,so1Vmeke,gmin sae,etc.
® ft. ltyo it _ t
4.Date Well(s)Completed: ZP 1` aZ Well ID# + T y® 3� t
5a Well Location: Phone # ��Q.� `e,�'�
' ` v� d � CQ6���•- ft ft.
F /OwnerName Fadlity IDA(if applicable) ft, ft
ft. ft
O•64©1A c to ,
Physical
Address,City,and Zip ft ft. ME 11 Z022
.21.RRMARTIR
�6 ]tl�`_s'c'�
County Parcel Identification No.(P!N) NUM'+r'l c•. �.n ,; .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,onelaUloagis sufficient) 22.Certification:
1�� N '$rl Q9- %V'; W WM G G 3Z
6.Is(are)the well(s): @kIrmaneut or ❑Temporary Sign of C ' ed Well Contractor Date
.By signing thlsform,I hereby certbry that the wells)was(were)constructed in accordance with
7:Is this a repair to an existing well: ❑Yes or AD 15ANCAC 02C'0100 or ISA NCAC 02C.02D0 1Pell Construction Standards and that a copy
If this is a repair,fill out known well construction informalfan and explain the nature of the of ibis record has been provided to the well owner
repair snider#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT oi=Closed-Loop Geothermal Wells having the same You may use.the back of this page to provide additional well construction info
construction,only 1 GW l. needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarics Box).You may also attach additional pages if necessary.
drilled: �( 24.SUI3MTITAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 da s of well completion per the following: 4)
For multiple wells list a!1 depths tf different(example-3(a3ZOD'and 2®I00) Y ; P P g%
10.Static water Ievel below top of casing:
too ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft. Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
if-water level Is above casing,use"+
11`°$orehole diameter: (in.) Bit Off: •��S 24b.For Injection Wells: Copy,,to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc) county environmental health deparhrLent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Wafter Wells producinlr over 100,000 GPD:Copy to DWR,CCPCUA
f Permit Picgram,1611 MSC,Raleigh,NC 27699-I 611
.Xi
13aeld(gpm) (A Methodof test: 99
13b.Disinfection type: 70%HTH Amount: 'a OZ DATE SITE VISITED:
o� I
Pri rr�
VISITED BY: ,Cf Af