GW1-2022-06644_Well Construction - GW1_20220711

EII,— a�NS i'iRUC1T��1�T 11�Jd-'�C ➢ � �1-1� For Internal Use Only:
1.Well Contractor Information:
�aA i
C� (nit) vT 14.WATER ZONES
Well Contractor ame F®fit ft. ftTO DO�� ��c
A '�
ft. � �
NC Well Coatractor CertificationNnmber 15,OUTER CASING for multi-rased SYells ORLINER if a linable
YADKIN WELL COMPANY,INC. FROM To D1kW=Tr tt- THICKNEss MATERIAL
ft. ft. in.
Company Name
/� 16.INNER CASING OR TUB eothermal dosed-too
2.Well Construction Permit#: Al/A FROM TO DIAML+TER TMCICNM, 5 MATERIAL
List all applicable well construction permits(Ia.EUC ounty,State,Variance,etc) ft in.
3.Well Use(checkwell use): f,- ft. in.
17.SCREEN
Water Supply Well:
PPY FRo➢s To DIAMEMR SLOT SIZE mclaYLss MATERAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 91
//esidential Water Supply(single) ft. ft. in.
❑Industrial/Commeroial ❑Residential Wafer Supply(shared) 1B.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL FWRLACEMENTAM,TROD&AMOUNT
Non-Water Supply Well: ft ft.
❑Monitoring ❑Recovery it ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK If 2 livable
❑Aquifer Storage and Recovery ❑Salinity Barrier moil TO MATERIAL 7FEMYLACEMRNTM=011
❑Aquifer Test ❑Stormwater Drainage ft I
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) []Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM zot. DEsc Tiox tutor, ,ragas,sui0rock a gm in sae ete
5,1a
4.Date Well(s)Completed: � Well ID#�� ® l' ft ft �}ant
5a Well Location: Phone
ft ft '.
Pr o�.(
Facility/OwnerName ,r FacilityM#(if applicable) ft ft
ft. ft
Physical Address,City;and Zip - ft ft g '�L
�
County (� Parcel Identification No.(PIN) Cum; ?Leae 7
5b.Latitude and longitgde in degrees/minutes/seconds or decimal degrees: �ds4ti w RIG
t.
(ifwell field,one lat/longis sufficient) y 22.Certification:
N 371�i e S 7�c�
6.Ware)the well(s): 24'rmanent or ❑Temporary Si e o ed Well Contractor Date
By signing thisform,l hereby certify that the wells)was(were)constructed in accordance with G
7.Is this a repair to an existing well: OYes or llto 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Fell Construction,Standards and that a ropy
If IhIs is a repair,fdl out known well construction rhformation and explain the nature of the of this retard has been provided to the well owner
repair under 121 remarks section or.an fhe back of this 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 OW I is needed, Indicate TOTAL NUMBER of wells (add See Over`in Remarlcs Box).You may also attach additional pages if necessary.
drilled: I 24.SUBW=AL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths lfdifferent(emmple-3©200'and 2@1000 �Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: (ft) Information Processing UA 1617 MSC,Raleigh,NC 27699-1617
Tjwoter level Is above casing,use"+" �7
Bit Off. 7 L 24b.For Injection Wells:Copy to DVA;,Underground Injection Control(IUQ
11.Borehole diameter: (IL) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-L'oop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d,For Water Wells producinglmIover 100,000 GPD:Copy to DWR,,CCPCUA
�` Permit Pmgram,1611 MSC,Raleigh,,NC 27699-1611
13a.Yield(gpm)�_ 1Iethod oftest:
76%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: _ tn ,/�