GW1-2022-06629_Well Construction - GW1_20220711

CTION RECORD (GW-1 V For Internal Use Only: f
1.Well Contractor information: I
1 14.WATER ZONES I '
FROM TO DESCRIPTION
WellConbrattorName ��fft
NC Well Contractor CertificationNumber 15.OUTER CASING formiulti-cased webs)ORLIHEj(ff8P13tij-b1e) F'
YADKIN WELL COMPANY,INC. xoTIiIC ft in.
Company Name 16.INNER CASING OR TUBING eothermal closedl2.Well Construction Permit#: ellFROM TO DIAM TIER TfficraList all applicable well construction permits(i.e.EUC,County,State,T,4riance,eta) ` ft '�'I ft 1 1➢' .5/1 q , p��
3.Well Use(check well use): ft. d' ra L/
17.SCREEN
Water Supply Well, rROM TO DIAMETER SLOT SIZE T1110WESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft, in,
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERAL EMPLACENI NT nSCTROD&AMOUNT
Non-Water Supply Well: ft lit. �isil nr '� �r{-*!r,_f vw'-e
❑Monitoring ❑Recovery it a ft.
Injection Well: g., fL j
❑Aquifer Recharge ❑Groundwater Remediatiqn
19.SANDIGRAVELPACK(if applicable)
❑Aquifer Storage and Recovery (]Salinity Barrier FROM To MATERIAL EwLACEMENTMETHOD
❑Aquifer Test ❑sio aterbi linage
❑Experimental Technology ❑Subsiderice:,Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessa C
❑Geothermal(Heating/CoolmgRetuin) ❑Other(expiainundei'61Renlarics) oM xo DFscraPTiox ealarlsaran�s.sovmrx is:;zeft fL
eta
d:
4.Date Wells)Complete �.��';�Well ID# L: .. '�� ffi �� f' o l� i.
a-
/.. qr fL Q
5a.Well Location: Phone#_ 375r3`"r,4 ".%���Z �� ft �-
' L�'ft ,ft
FacilitylOwmerName Facility IDA(if applicable) r ft t-y�•/.� o� y e-
o rYt �r Pam( r&& ft. ft
G„
Physical ddsess,City,and Zip ft ft r,F y !t. 10
l ,!k-rtr� 21.RENLauu�
w'i
County Parcel Identification No.(PIN) J U L
11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;, w Y'•" f�
(lfwallfield,onelaMongis ssu►ffiycient) u` I
/ 22.Certification: v, s"a-(��) ��(��r1-�v �C7
3 ��E/S(b/•2, N t (it!s'�b W Irli t�i,�w
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date Q
By signing thisform,l hereby certify thdt the wens)was(were)constructed in accorddnce with
7.Is this a repair to an existing well: ❑Yes or ° 0 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that 6 copy
If this is a repair,fdl out,brown even construction hnformation and erplam the nature of the of this record has been provided to the well awrrer
repair under#21 remarkssection or on the back ofthisfonn. 23.Site 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 mfv
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: L 24.SUBMITTAL INSTRUCTIONS
l
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 Ifdlfferent(rsample-3(a)200'and 2@1001
(f ^IL 242. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ` U (ft) Information ProcessingUnit 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
Il.Borehole diameter- (in.) Bit p{f; 24b.For Injection Wells: Copy to DWI;,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.WeIl eonstrnction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return We1Is:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produ8nrl over 100,000 GPD: Copy to DWR,CCPCUA
!1 i Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) O{ Method of test:
70%HTH A OZ DATE SITE VISITED:. �-3
13b.Disinfection type: mount: t l
- -I - -- -- -- - - -- - VISITED BY:1/J'