GW1-2022-07480_Well Construction - GW1_20220810

LL'Co�S 1 lUC;1T�D1� iC't� ➢fV�-1� For Internal Use Only:
1.Well Contractor hiformntion:
:,e SC( / �Q ft•f MS 14.WATER ZONES' �1
Well Contractor Name FROM TO DESCRIPTION
ft. GO ft. _&4_PM =
4 ft
NC We11 Contactor.Certification Number is.OUTER CASING for multi-cased wells OR L1NFR rf a licahle
YADKIN WELL`COIVIPANY,INC. FROM To DIOMTER THICxivEss MATERIAL
ft ft.
Company Name
16.DUM CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: t-214 V R 35- FROM TO DIAMETER I THICMIMSS I MATERIAL
List all applicable well construction penults(ae.UIC,County,State,Variance,etc) ft o ft / Y x'' 11LV f n,
v •
3.Well Use(check well use): & 1II'
Water Supply Well: 17.SCREEN
FROhT TO DIAMETER I SLOT SIZE I THiCrt1YESS MA'rRuIer.
[]Agricultural ❑Municipal/Public ft. "- 'n=LE
❑Geothermal(Heating/Cooling Supply) Atesidential Water Supply(single) ft ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1B.GROUT
DIrrigation OWeils>100,000 GPD FROM TO MATERIAL EMPLACEMENT ATETHOD&AMOUNT e'
Non-Water Supply Well: ft. ft. Pali red! r-k' � S
❑Monitoring ❑R.ecovery M ,y ft. amp—
Injection Well: ft. fL
'OAquifer Recharge ❑GrmmdwEter Remediation
19.5ANDIGRAVELPACK da licable) T
❑Aquifer Storage and Recovery ❑Salinity Barrier FRonf To MAIEurer. :' EM]MACEMEN METsoD
❑Aquifer Test ❑3iormwater Drainage
ftI peiamental Technology ❑Subsidence Control ft. ft. irC
F ❑Geothe>mal(Closed Loop)likk, A ❑Tracer s 20.DRILLING LOG attach additional sheets if necessa ! G
3 f'r' FROM TO DESCRIPTION color,hardness,w1kock .'n ays,ctr-
❑23eothermal(Heating/Cooling Mcr) ❑O(A?( lam under#21 Remarks) �Z
4 )Date Well(s)Completed: I a WellW-# 'AAA— W41 ys ft l e- ,
5a.Well Location: Phone # ;Q 0:• ft M
€
/ L 1 ,�e 1� J1jGs �arr�s�ce C
P�J7 O� ,bh. _ Pf>ficti
Pactlity/OwnerName PactvfyIIJll(ifapplicable ft ft �' s
�"�$'k ft ft AiJ G ! 0 2022 e.
Physical Address,Ctly,and Zip ft
` UM
21.REMARKS 1
a Coon s`' " PateelIdeatificatioallo.(FIld) ' —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwallfielk one lat/longis sufficient) 22.Certification: •
3C , �qS3� N t �.HS W
Wd6 ' 7 2 rt
E.4(are)the w ell(s): Permanent or ❑Temporary Sign of ed Well Contractor Date
By signing thisform,I hereby certiry that the wells)was(were)constructed in accordmca w-
7.Is this a-reparr to an eidsting well: ❑Yes or KNo 15ANCAC 02C.0100 or I5A NC.4C 02C.0200 Well Construction Standards and that a'6' -
If iris is a reppir,fdl out blown well construction utformatian and explain the nature of the of this record has been provided to the well owner.
repair under f21.remarla section or on the back of this form. L
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sameYou may use the back of this page to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remario;Box)..You may also attach additional pages if necessary.
drilled: / a� 24.SUBN=AL INSTRUCTIONS
9:Total well depth below land surface: a'O Do
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3Oa 200'and 2@1001
`. O 24a. For All Wells: Originaliform to Division of Water Resources (DWR),
10.Static water level below top of casing: a (ft.) Information Processing Unit 1617;MSC,Raleigh,NC 27699-1617 ,
Ifwaier level is above casing,use"+" :t
�p Bit Off: I. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) '
1
11.Borehole diameter: (in)
• Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12:Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(r.&auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
t ( Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ale
13b.Disinfection type: 70%HTH Amount: 30 OZ DATE SITE VISITED:
pri c-P_ I _��tV151TED BY