GW1-2022-07585_Well Construction - GW1_20220815

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c�.QNS�iNC 1TIQ REICQ RD��GW-�l For Internal Use Only:
1.Well Contractor Informatio
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: ' L
Jc�cti Woc�FtA-5 1 14.WATER ZONES
Well ConfractorName FROM TO p1tSCnIPiION _ S
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ft. ft.
7q 5.7 A fr. it
NC Well Contractor Certification Number 15.OUTER CASING for multi-used wa OR LINER if a Gcable
YADKIN WELL COMPANY,INC. FROM To DrAM:�TEa Tffic�rEss MATERIAL ftT
ft, fL in.
Company Name y �y 16.INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit#: Q l D S 3 90,7l! FROM TO DIAeII=R THICKNESS MSATERIAL
Lisl all applicable well construction permits(t,e.WC,County,State,Parlance,etc) t ft I I LI ft / V4 in' -solo
Ro
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN r
FROM TO DIAMETER SLOT SIZE TSI0QYLSS M24TERI4L.
❑Agricultural ❑M impaVPublic it. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Non Water Supply Well: a ft. Jr f' 04P PoVfeJ s►
❑Monitoring ❑Recovery S IL A? ft. a (xOv{ Pu "f
L
'
Injection Well: it ft
❑Aquifer Recharge oGroundwater RemedIation
19.SAND/GRAVEL PACK(Happlivable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRord TO MATERIAL. EMPI.ACEtVMNTM=I OD
❑Aquifer Test ❑Stomiwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG atfach additional sheets ifnecessary)
❑Geothermal(Heating/Cooling Rehmn) ❑Other(explain under#21 Reman?3) OM ft 1 D 7 g, DE S CRIFTIOx color,hardness,soiurnek in size, c et
I TO
all
4.Date Well(s)Completed: We11IIJ# Aft 149 /0`7 ft 3ti' 6r4oni irU
ft. f- b
. Sa.Well Location: Phone # f Yfdk,Sr,; k-?
ft ft
i
'Facility/OwnerN a f�11 2iiyl #((iifapplicable) ft ft , 1
pf1►8 k�aUl �K r df[fy�v,�(�.� ft. ft and Zip ft ft. `
Physical Address,City, yin J ;
�ca 1y`v% 21.REMARKS T�.�°9
Can* $� Parcel Identification No.(PIN) 4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification: (/
36� (Y4: CO2 N 9-a4 -Cr,JR-4k -W4.AS.,,ef ( A )Ak,
6.Is(are)the well(s): a Permanent or ❑Temporary Sigoahte of Cerped Will Contractor Date
By signing this form,]hereby certify that the well(s)was(were)constructed in accordmice with
7.Is this a repair to an existing well: I]Yes or 80 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a copy
If 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#21 remarks section or on the back of thisfarm. 23.Site diagram or additional well details:
B.For Geoprobe/DPT or©osed-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 lhdicsda 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: !003 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(=ample-3@200'and 2@700D
242. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-16I7
IfwQier level/s above casing,use"+"
Bit Off: .0SZ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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:Copyto the
(Le.auger,rotary,cable,direct push,etc.) county environmental health dep larhnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing!Over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 e C
13a.Yield(gpm) Method of test: Q t r
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: 16'a 7-2 Z
VISITED BY:� f�✓,°,�