GW1-2022-08181_Well Construction - GW1_20220408

For Internal Use Only:
I.Well Contractor In_tormntion:
1 d'� Ca v e- 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
If ft.
APR 0 8 202? 1 U ' . ftMALas
NC Well Contractor Certification Numbe 15.OUTER CAMNG forrdulli-re wells RLIIVPER'da "ilea a 1t ke "�s °ky1
YADKIN WELL COMPANY,INC. FROM To DrAMETER" TzszCsxEss MATERra1
ft ft
apw-
Co an Name
' 16.INNER CASING OR TUBING thermal Cl
2.Well Construction Permit#: ?'43173 FROM TO MLTSR DIA Tm0aws MATT RlAL
List cll applicable well construction permits rz•e.UIC,County,State,Variance,eta) it it' in.
G✓� ► ,
3.Well Use check well use): ft 6 ft• in. z'
Water Supply Well: 17.SCREEN �,
FROM ' TO DIAMETER I SLOT SIZE TffiCIaVESSa';'I i&VA IAI 1t
❑Agricultural ❑Municipal/Public ft,
❑Geothermal(Heating/Cooling Supply) PKesideritial Water Supply(single)
ft ft. in. yZ,
❑Industnal/Commercial ❑Residential Water Supply(shared)
19.GROUT
DIrrigation. ❑Wells>100,000 GPD FROM TO. MATERIAL EMFLACEMENT,METHOD`&TAMOUNTJI
Non-Water Supply Well: ft. ft' 1! 'Fe 'S" y ���
❑Mnnitoring ❑Recovery it ft. x_" j
' Injection Well- AWN
R71.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable paG.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLiCCEMENT:METHOD
❑Aquifer Test ❑Stormwater Drainage r ?
❑Experimental Technology ❑Subsidence Control
❑Geothemlal(Closed Loop) ❑Tracer 20.,DRHAMG LOG atfach additiotW khefti if necessa
FROM I TO DESCRIPTION rotor,hardaess'-i6l roe''"+ TtQTctc llr
❑Geothermal(Heating/Coolmg Return) ❑Other(explain under#21 Remarks) fL
)y
r.-
4.Date Wells)Completed:_ '� Well ID ",` Z' ftp�'ft° `�'
G ''ireh '
�^ •1ft
Sa.Well Location: rx Phone # po�t� G�•L�30 �` i6 1`rlds�a�
/Qoll�GrtS�sod�f� �'�� '
� �Z �. �.t �R�sv mow^ I /ia �+�■
Fact /OwnerName Pacility Mff(if applicable)
99(: na�: � ,. _.�a• ..Qom,�!,'
/pad
Physical Address,City,and Zip
2LRRMARKC..:"County Parcel Identification No.(PIAI) I I +•• ' �lu W 4"t s..• _, /G'u� &G,L, 1►7
5b Latitude and longitude in degrees/minutes/seconds or decimal degrees: I°� ��
(ifwall/f�i_eeld,one lat/lo�yn/.gis sufficient) P J` ay.' uff
22.Certification'
34 a 5a i 7 J N 87 .4 I 1VL Z®
6.Is(are)the well(s): Ofermanent or ❑Temporary Signature of Certified Well Contractor Dinh "5
By signing thisfoi*,I hereby cero that the well(s)was(wer4 cansd icieit in accardmtce with
7.Is this a repair to an existing well: ❑Yes or L° 0 ISANCAC 02C 0100 or_l5A NCAC 01C.0200,Deli Constracttan SYm immdr and tltota wpy
If this is a repair,fill out known well construction information and explain the nature of the of this record has bear pidvlded to the Weil owner" t � �
repair under i21 remarks section or on the back of this form.
23.Site diagram ar additional well details: � eg
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the'back of this page to provide additionalwell coDsh Iction iDfo
add'See Over'm Remarfm Box You m, ` Se.�
construction,only 1 GWis needed. Indicate TOTALNUMBBR of wells ( ) may also attach additional p" — Essary.
drilled:
24.SiJBMTrrer INSTRUCIT014S
9.Total well depth below land surface: 30�
For multiple wells fist all depths if different(example-3©200'and 2®100D Submit this GW-1 within 30 days,of well completloD';per the/
24a. For All Wells Original form to DiAslo$ of Wafer 1
10.Static water level below top of casing:_ (ft) Information Processing Unit,-1617 MSC,Raleigh,NC 27699-1i
lfwater level Is above casing,use"+" r r l
11.Borehole diameter: (in•) Bit Off: V�' 24b.For Injection We Copy to DWR,Underg 6prid In'
Program,1636 MSC Raleigh,NC 27699-1636
12 Well construction method: AIR ROTARY
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Su I and O en Loo' Geothermal Re
courrty enviromncntal health department of the cointyr vli"
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells producing'over 100,000 G#De
Q air Pemut Program,161.1 MSC,Raleigh;NC 27699-1611'
13a.Yield(gpm) Method of test:
13b.Disinfection type: 70%HTH Amount, OZ DATE SITE VISITED: .. 3•' .2-2 ,
V:
i Y: �/�