GW1-2022-06611_Well Construction - GW1_20220711

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w9 EI.1;CONSTRUCTION RECORD CORD(GH-11 For Internal Use Only:
�I.Weil Contractor ln-t'orrantion:
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1- B B f cma ri k`+q 14.'YVATER ZONES I I ®_
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Well Con lractorSVame FROM TO DSSCRIETION
566 �� �b ono y' r�. s� j
NC Well Contcactor Certification Number ®�' �75� rrC� s '�'�
15,OUTER CASING for multi-cased-vvells ORLll ifa linable 1
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNEss MATERIAL
ft. I ft. I !• 'in
Company Name gam^,a fy �, `7 09- 31 x v 16.INNER CASING OR TCBING('eothermal closed-loop)
2.Well Construction Permit#: aQ� S2-Dje, I FROM To DIAhI= TffiCIt. = MATERIAL
List all applicable well construction permits(La.L11C,County,State,Variance,etc) t' 0 ft. � ft ! in.
3.Well Use(checkwell use): ft ft. in.
Water Supply Well: FROM�E To DUMETER stoT slzE THtCInvEss MaTERwL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
1B.GROUT
gation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMMTATETHOD&AMOUNT
Nan-Water Supply Well: 0 � ' i v t;
❑Monitoring ❑Recovery - I ft 2, ft' PLrA 0 4t
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENTM=- OD
❑Aquifer Test ❑St imwater Drainage ft ft
[]Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) []Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM To DzscRiTnON corer,hardness,WYracktypr,gnun sire,ere
o ft e7 6 ft. C-I C, S at
4.Date Well(s)Completed: ?',We J TD# ® t O 01 Mei rC t;'ft
Sa.Well Location: Phone 11 V'3
s �. k i - ft ft
FacIlitylOwnerName PacilityM#(ifapplicable) ft ft n
12
p ft. ft
fidbAws
- A--- n �'B9 i�Vj�
Physical Address,dy,and Zip ft M s .
•' 21.REMARKS Q -
Res,` �
Coumy Parcel Identi fiicationNo.(PIN) jut
5b.Latitude and longitude in degrees/udnutes/seconds or decimal degrees: ,
(ifwellfield,one Wong is sufficient) 22.Certification:
�SI IN t
N e �9 w 11j:i 0 6—3®—ZO LZ
6.Is(are)the well(s): @Tfermanent or ❑Temporary Sign of Ce ' Well Contactor Date
By signing thlsform,I hereby cerijfy that the wells)was(were)conducted in accordance with
7.Is this a repair to an existing well: ❑Yes or & o 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repalr,fdl out known well construction irl/ormation and explain the nature of the of this record has been provided to the well ownen
repair underi21 remarks rsection oran the back ofthisform.
23.5ite 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
consbuction,only 1 GW-1 is needed, Indicate TOTALNUMBER of wells (add'See Over'in RemarIcs Box).You may also attach additional pages if necessary.
drilled: 24.SUBMr1TAL INSTRUCTIONS
9.Total well depth below land surface: 663 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(emmple-3 aC1200'and 2@100�
24s. For All Wells: Original form to Division of Water Resources (DWR),
10.5taticwater Ievel below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"r
11 Borehole diameter: ® (in.) Bit Off' ° y 24b.For Infection Wells:Copy to DWI;,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(La.auger,rotary,cable,direct push,etc.) county environmental health deparmnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) f Method of test: 0: t' Y&r 1 1
13b.Disinfection type: 70%HTH Amount 2 OZ DATE SITE VISITED: -'��"'2- 2'
Uri na
- VISITED BY:_r