GW1-2022-07577_Well Construction - GW1_20220815

° ,L CCQNSr1PIT�U 1TIQN�T R,C0�dGW-i11 For Internal Use Only: I
I.Well Contractor lnforg�tion.
{/`O t,(•S� .N1
1Cpep I''t / 14.WATER ZONES
$ FROM TO I DESCRIPTION
Well Contractor Name , 5 ft• ,b
I � �
NC Well Contractor Catfieation Number
15.0UTERCASING formnlH-ras�dvrells OR LINER rfa ticable
YADKIN WELL COMPANY,INC. PROM TO DIAMETER TffiCKNESs MATERIAL
_ ft ft in.
Company Name �� �+3 1 e'� 16.]INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: O Co o( �W pl
FROM To DMhUTEn TfficlavEss MATERIAL
List all applicable well construction permits(4e C,County,State,Variance,etc) G ft / ft G ,05 in. SD / I1
3.Well Use(check well use): ft V ft in. / [/ �11
V
17.SCREEN
Water Supply Well:
PROM TO DIAMETER I SLOT SIZE I THICIOVESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM I TO MATERIAL EraLACEMMT METHOD aAMOUNT
Non-Water Supply Well: ft
+� st
❑Monitoring ❑Recovery it ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft
19•SAND/GRAVEL PACK(if applicable)
❑A uifer Storage and Recovery ❑$8h mtyBarrjm
FROAf TO ARTERIAL EIlII'LACEMI+NT 1v=- OD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 10,DRUJMG LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Renlalia) FROM To DBSCRIPTION color,hardness,soiUrock ain sae,ete
ft 30 o
4.bate Well(s)Completedid` '7—Well INiMf- O ft 100 ft �tiaCl
5a.Well Location: Phone #_70K-9'Tt7-:?Q ffQ too fL 322 ft' h !l Il
7 �? /*e h A v r' ft it
rf s m
Fact•ty/OwnerrNamme �j /P ,Facility M#(if applicaabble) ft ft +, ,g T 5
ft. fL
2022
Physical Address,City,and Zip s/ fL R
� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/iongis sufficient) 22.Cer Lation:
G 13 .3'S Sl N ! D fit S3 w
6.IS(are)the well(s):Vermanent or ❑Temporary "K!>pif Certified Well Contractor Date
signing thisform,I hereby certdy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANo ISANCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
_ If thin fs a repair,fdl out brown well construction information and explain the nature of the of this record has been provided to they well owner:
'µ ipatrun erf21remarkssectionoron the back ofthisform.
23.Site diagram or additional well details:
' 8. o'Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well consruction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
a mead "
1 a 24.SUBMITTAL INSTRUCTIONS
9 Total well depth below land surface: (ft•
For mriliiple wells list all depths tfdi�erent(example-3Q200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water levtl below top of casing: 5 a (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level Is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: G 1 a 7Q S 24b.For Iniection Wells: Copy,to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Rsleigb,NC 27699-1636
12.Well construction method: AIR ROTARY
(it.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER 5 SUPPLY ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m ,�i Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP ) Method of test: 4"/1
13b.Disinfection type: 70%HTH ,Amount: (O' 1 OZ DATE SITE VISITED: t� —za
Pri rP
— VISITED BY: Pig i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ` Revised 6-6 is