GW1-2022-06626_Well Construction - GW1_20220711

y8'Ej LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
(On Gam 14.WATER SONGS I
FRol%l TO DESCRIPTION
Well Contractor Name ft. ftft ft.
NC Well Contractor eriificationNumher 15,pUTER CASING forniulti-cased wells OR LIlVER if a Iicable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TfficravEss MATERIAL
ft ft. in.
Company Name 16.INI ER CASING OR TUBING eotlrermal dosed-loop)
2.Well Construction Permit#: FROM a TO D TMCIa4Ess n4ATERIAL
LW all applicable well construction permits ri.a.171C,County,State,Variance,eta) ft ft. in. aq PVc
3.Well Use(check well use): ' m.
Water Supply Well: I
27.savFriMom I To. DIAMETER S CtaYESS I MATERIAL
❑Agricultural ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) ,Kesidential Water Supply(single) ft. t, in:
❑Industrial/Commercial ❑Residential Water Supply(shared) le.GROUT
01nigation ❑Wells>100,000 GPD FROM To I MATEnIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
❑lylonitoying ❑Recovery ft.
Iuieetiou Well: g fh
❑Aquifer Recharge ❑Groundwater Remediation
I9.5AND/GRAVEL PACK(rf a livable)
OAC}iifer Storage and.Recovery-, DSalinity Barrier FRoN! TO MATERIAL En2LACENMNT?=OD
❑Aquifer Test 'a. '`'r:x ❑S-6imwaterDrainage ft
[7Ezperimental Teohnoldgy"'; -l7Subsidence Contirol ft ft
OGeotheanal(GlosedLoop) [7Tracet 20. GLOG attach additional sheetsifnecessa
s ,
= th mFROM TO DES ON coor-Ladnespo&nrc ¢
cadhermal(Heating/Cpolid t e # etc
4.Date WelI(s)Completed: WellID#�T �e 1 ft
S,L WeR o'ca an'.
s+Phone #
ft
t'n
- .�:. ft ft �vv1 a_nx
Fac�7ity/OwnerPlame a FacilityID#(ifgigeable)
ff- ft JLUV.V
Physical Address,City,aad ZiP �,�L'Ldp'd h� r20C4C WAVE
ft. it.
21.REMARKS
Foc-
County Parcel Identification No.(F1N) 911
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: UO "
(ifwau field,one lat/longis sufficient) 22.Certification:
wnd�) 6 -�O 70-
6.Is(are)the well(s):Aermanent or ❑Temporary Signature of Certified WellContmctorl Date
• By signing thisform,1 hereby certify that the wall(s)was(were)constructed in accordance with
es or MNo,do e �� ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction,Standards and that a copy
7.Is this a°repair to an e3dsting7elI
rthis is a repair,fdl out known well consiruc ibm bPrmation and explain the nature of the of this record has been provided to the well owner
repair under f21 remarks section or on the back ofthis 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_I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages If necessary.
drilled:,_ rr //tp� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(example-3(a)200'and 2Q100�
f� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: w0 (ft.) Information ProcessingUait,1617 MSC,Raleigh,NC 27699-1617
61 -ter level is above casing use"+"
t ?�)b.For Irriection Wells: Copy to DWR,Underground Injection Control(RTC)
11.Borehole diameter: (in.) Bit Off' Program,1636 MSC,Raleigh,NC I7699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return WelIs:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY LLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
r� PermitPmgrarn,1611 MSC,Raleig"'111C 27699-I611
13a.Yield(gpm) � f Method oftest: �/T/P , I',,
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: -�—