GW1-2022-07558_Well Construction - GW1_20220815

WELL RCONST CIT1I+m RECORD(GW-11) For Internal Use Only:
�'V4 e11 Carl for Informntion: _•
C._./1li`KL�s.)000tAtL ��� 14.WATERZONES 1 (�
FROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor CertificatioaNumber 15.OUTER CASING for multi-cased Wells)ORLWFR if a licable
YADKIN WELL COMPANY,INC. FROM To I DIAM¢TER THICaNESS MATERIAL
® _ - � k. �3 ft. ��� in. , � /d�•.%'lid '--
Company Name �.Sra� 1-19 ZJ 16.INNERCASINGORTUB)NG 'eathermaldosed-]oo
2.Well Construction Permit#: PKWL 2aZ2 d 11W4 FROM zo nLAMETER rfficTavEss NfATERIAL
List all applicable well construction permits rLe.U7C,County,State,Variance,eta) ft ft in.
3.Well Use(check well use): ft. in.
7Z
Water Su 37.SCREEN /1
Supply Well: •PttOl1S TO I DIAhSE1TrR SLOT SIZE THICIOYESS MATERIAL Cl
❑Agricultural ❑Municipal/Public ft. ft, la•
❑Geothermal(Heating/Cooling Supply) Qj4dential Water Supply(single) g ft,
❑Industrial/Commerciai ❑Residential Water Supply(shared) 16.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: l ft. /�, ft. �K'balrtC( � H I�'>� N QL'
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft, ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK d Applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier mom TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage, ft ft
❑Experimental Technology ❑Subsidence Control. fr. '
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION colloor.hardness,so7Vrurk she,etc
❑Geothermal(Heatin CoolingRt tum) ❑other(explain under#21 Remarks) it O R. S tD (� fSof
4.bate Well(s)Completed:&?/.2dQdAWellID# )v ft '7 CP L a .► ' F btk • 1o:t 4
Sa.Well Location: Phone # 336- /'' Qb�® In ft. 13 IL
�r�►qi
IL
fL G Ne.«
e•! + C
MaLflity/O erName FacilAyM#(ifapplicable) R ft
0
ft ft.
Physical Address,City,and Zip 21.REMARKS .
9(Air N'U v
County Parcel Identification No.(FIAT) -a s:r urlil
1nfLx�'�':r�nt:l,'vOG
5b.Latitude and longitude in degrees/minutes/seconda or decimal degrees:
(ifwell field,one lattloagis sufficient) ertifica
.� sign ed Well Contractor Date
6.Is(are)the well(s): I�Yermaneut or ❑Temporary
arg thisfonn,1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or C710 1 SANCAC 01C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a copy
if this fs a repair,fill oul known well construction k ormation and a latn the nature of the of this record has been provided to the well owner. �(
repair under 411 remarks section or on the back of thisform. 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 info
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:, ( , 24.Sj BMITTAL INSTRUCTIONS
9.TotaI 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 If different(example-3@200'and 2@1001
24a. For All Wells: original form to Division of Water Resources (DWR),
,10.Static water level below top of casing: (ft.) Information Processing Uait,1617 MSC,Raleigh,NC 27699-1617
Tfwater level is above casing use"+" 1
t; Bit Off' •��D 24b•For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (-•) 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
(i.e,auger,rotary,cable,direct push,eta.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciI mover 100,000 GPD: Copy to DWI,CCPCUA
I [ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ` � �•-+ Method of test: �/'
70°h HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount
VISITED BY: (lJ/S