GW1-2022-06613_Well Construction - GW1_20220711

i
pNd ERECORD(G'VV-1) For Internal Use Only:
I.Well Contractor Information:
14.WATER ZONES 1
FROM TO DESCRIPTION
Well Conhacto�r e
ft. ft
NC Well Contractor Certification Number 15.OUTER C used w ASING for multi- ens ORLINER if a linable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TJU=BS MATERIAL
it, ft in.
Company Name 16.neUR CASING OR TUBING eothermal rlosed loo A�J
2.Well Construction Permit#: c� �'._.r IF!
xo DIA ETER TfficlQlrss nurc[uAL
List all applicable well construction permits(i.e.EUQ County,Slate,Variance,eta.) / it r O in. 5A9-� f/C
3.Well Use(checkweil use): fL ft i rn
Water Supply 17.SCREEN
PP y Well: ; FROM TO 13L MM_ ER SLAT SIM THICIOYESS MATERIAL O
OAgriculturaI • 6Municipal/Public ft. ft,
❑Geothermal(Heating/CooIing Supply) CAR sidential Water Supply(single) . ft.
it
❑Industrial/Commeroial ❑Residential Water Supply(shared) 18.GROUT
❑Isigation ❑Wells>100,000 GPD I FROM TO r MATERLiL EMPLAC=M11%ETHOn&AMOIINT
Nan-Water Supply Well: b it. V ft. - ��• 3 �`
❑Monitoring ❑Recovery t( fL ft.
Injection Well: g,
ElAquifergecharge ❑Groundwater}temediation 19 SAND/GRAVEL PACK Wa liable)
❑Aquifer Stomp and Recovery []Salinity Barrier FROM TO MATERIAL En?PLacCM NTML;TaoD Cz
❑Aquifer Test ❑StormwaterDrainage ft it n p@
l
❑Experimental Technology ❑Subsidence Control ft.
❑Geothemral(Closed Loop) ❑Tracer 20.DRIId1NG LOG attach additional sheets if necessa
FROM To DESCRIPITON color,Lardness,saVrock e, 'a sas,etc.
❑Geothermal(He ating/CoolingRetarmn) ❑Other(explain under#21:Remarks) ® ft C ��
4.Date Well(s)Completed:6•-J&a WeU!D# Utt P ® ft ly f ft. my
fL
Sa.Well Location- 0 Phone#a�L �. l1 ,�
�m��J�d �dZ•ff���c��e� . - ft• ���� Ord' /f'i'°e �''ti•
Faoity/OwnerName p FacilifylD#t(ifapplicable)
ri ft
4 � �� �a Flu_ ft. ,�.
-�,
Physical Address,City,and Zip ft ft. { if
; A 21.REALUM
County Parcel Identification No.(PIM
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees- :::
(ifwellfield,one lat/longisSufficient) 22.Certification: �eiL3 91�b o
N ` /K 9 2_g, e7 W a�3y
6.Is(are)the well(s): 2fermanent or ❑Temporary Si of Cmwd Well Contractdr Date
By signing thisform,I hereby certjfy that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 15A NCAC 02C.0100 or l5A NCXC D2C.0200 Well Construction,Standards and that a copy 1-4
Ifthis is a repair,fill out known well construction information and explain the nature of the ofihis recordhas beenprovided fo the well ownm
repair under#2I remarks section or on the back ofthisforin.
23.Site diagram or additionalivelI details:
8.For Geoprobe/DYT 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 GAP 1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).'You may also attach additional pages if necessary.
drilled: 24.SUI31YfITPAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if difjerenf(uample-3(a)200'and 2@100)
70° Isla. For All Wells: Original form to Division of Water Resources (DWR),
-10.Staticwater level below top of Casing: (ft.) ,formation Processing UA 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
a (in.) Bit Off' o®�® 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter
• Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and 0 '- oop Geothermal Return WeIIs:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmentaI health depiar rnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produeinLi over 100,000 GPD:Copy to DWR,CCPCUA
B Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield fgpm) J Method of test:
70%HTH �• OZ DATE SITE VISITED:
13b.Disinfection type: Amount: ��rp_�
- ViCI-Mn RV• R.�r Y