GW1-2022-06630_Well Construction - GW1_20220711

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WEg�`•f•.,QNS RUCTION REODED(GVV-11) For Internal Use Only:
1.Well Contractor Inforriantion:
!
U-)CA,Ic(ns1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name Awfi. I am ft.
J`�i4 1 to ft• l is ft !apron �-�G I Id.
(it
NC Well Contractor Certification Number 35.OUTER CASING for multi-cased walls ORLWF.R if a licahle v
YADKIN WELL COMPANY,INC. FRoM To DIAMI4TER THIt3 MS MATERIAL
_ ft ft � in.
Company Name W i(�e_S 0.76- 6 �� 16.IlQNERCASINGORTUBING( eothermaldosedloo )
2.Well Construction Permit#: 6�4 q/ FROM To DIAMETER THICIINrSs Rr4ATrureT•
List all applicable well construction permits(i.e.U1C,County,Slate,Trariancs,e(a) .t! It rt G in.
3.Well Use(ebeckwell use): ft. ft, m F•
17.SCREEN
Water Supply Well: FROM To DIAMETER sLorslzE TImCICNESS KATEIU41
❑Agricultural ❑Mimicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) it ft. in.
❑Industrial/Cormncrcial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑WeIIs>100,000 GPD FROM TO MATERIAL EMPLACEMENT A2ETROD&AMOU Tr
Nan Water Supply Well: Q ft' -3 ft' �O P� OdtrreJ
❑Monitoring ❑Recovery ft13 0 ` Gr0176 3s'
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGRAM PACK(if a licable)
❑Aquifer Storage and Recovery ❑SalinityBarrier I moM To MATERIAL WTPIACEMTNTMETHOD
gAquifer Test ❑Stormwater Drainage ft' ft.
❑Experimental Technology ❑Subsidence Control ft I ft. i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILISNGLOG attach additional sheets ifnecessa
FROM TO :o3s non rnior,lilydness,soiVrDck c, .in she,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under
y#121 Remarks) ft p ft �
4.Date Well(s)Completed: G I�j hat weuID# /i" - q yL 0 ft' 00 ft' 6 ma 04c
`� 2 ft
Sa.Well l,oration: Phone#.��„'�•a �9�� 9✓-��
f lI Y ft. ft
• s�d � ft. ft
Facility/OwnerNamc FacilityIDA(if applicable)
Physical Address,City,and Zip ft °"rn E D
_Ire 61/i�it✓j�' 21.REATAAICS `
County Parcel IdeatriicationNo.(PIIl)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �+
(ifwellfield,one lat/longissufficient) 22.Certification: .t 1 ` (��t�J3{i' UN,{IJi'G'Tivtr�ll�r{>3 ( G
6.Is(are)the well(s): dermanent or ❑Temporary Sign a of ertified Well Contractor Date
By signing thisform,1 hereby certify that the well(j)was(were)constructed in accordance with
7.Is this a repair to an existing well []Yes orl0 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction,Standards and that a copy
1f this is a repair fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geo robe/DPT or CI.osed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info-
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7d0 (ft') Submit this GW-1 within 30:days of well completion per the following:
Formultiple wells list all depths ijrd erent(example-3(a)200'and2Q100)
Z4a. For All Wells: Original;form to Division of Water Resources (DWR),
10.Staticwater level below top of easing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
(in.) Bit Off' & r 050 24b.For Iniectfon Wells: Copy to DWR,Underground Injection Control(RUC)
11.)Borehole diameter. 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 deparhnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodiici' over 100,000 GPD:Copy to DWR,CCPCUA
q Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) Method of test: Ar 87
00 �, DATE SITE VISITED: f'fi11 2%Z i
13b.Disinfectiontype: 70/ HTH Amount: OZ
t VISITED BY: 0 0n