GW1-2022-08389_Well Construction - GW1_20220513

For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well ContractoiName FROM TO DESCRIPTION
ft' 15
J5-7a ft. 1-7 IV 9 0 r,
NC Well Contractor Certification Number .xx'15,OUTER CASING for Aulti-taied wells)ORLINER(ffRpli�cablel
YADKJN WELL COMPANY,INC. FROM D10=T= TffiCLOVESS I MATERIAL
ft. ft. in.
Company Name 1
16.RINER CASING OR TUBING fieothe rlosEd-loou)
2.Well Consft uction Permit#: 21- 10 LtALH9-0q1L0 FROM TO DIAMETER I TffiCIINISs MATMUAL
List all applicable well construction permits(1.e-LUC,County,StatE,Variance,etc.) 41 'tLey ft G 'u.
3.Well Use(cbeckwell use)- ft ft. in.
Water Supply Well; 27.SCREEN /�
FROM TO DIAMETER SLOT SIZE TMCICNrSS MATERIAL
ElAgricultural DMunicipal/Public ft. ft. . in.
DGeothermal(Heating/Cooling Supply) , Residential Water Supply(single) --7-ft, ft. in
DIndustrial/Commercial DRasidential Water Supply(shared) 18.GROUT -
DIrrigatioll OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: Q ft, 3 ft �?m eA';Oj
DMonitoring EIRecovery ft .3.6 ft.F6,5yd",
Injection Well: ft. ft
OAquifbr Recharge CGroundwater Remediation
19.SANDIGRAVELFACK(if xopUca'ble)
DAquifer Storage and Recorvery oSalirity Barrier FROM TO MATERIAL rMPIACx1MLNTTV=1OD
DAquifer Test OStormwaterDrainage ft. ft.
ElExperimentEa Technology F-ISubsidence Control ft ft
0 Geothermal(Closed Loop) DTracer 20.DRILIINGLOG(attach additional sheets if necessary)
FROM To 3)ESCR=Ox(color,hardnst,50-2)frocktypc�gnin rbx�ctr-)
DGeothermEd(HeatingtCoolingRetinn) DOther(explain under#21 Remarks) ft
0 ft. ft _rt-a XjL-.e
t
4.Date Well(s)Completed: Weil]D#AAT0'-'-9 5- ft. IL Ab-%-,bo
3ft
5a.Well Location: 3 -20 ft vtrI.Wk SA
Phone # ft. fL 4.,
Sp4 dw(ADf4t a 0--
Pacility/OwaerNarne Facililyn*(if Axilicable) ft. ft NtULIVE'n
:r26q Ato#,-x#,%ce-CJ\ " ft. ft. MAY 1
physical Address,City,and Zip ft. ft
&(A;k-(0 � 21.REMARKS Inkmalion Proor-wsing UpA
County Parcel IdexaffiDaffinx No.CMD MWOOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cifwall field,one lattloag is suffident) 22.Certification.
2 2- -N -79 :7.. r,6 I ---�W �? P
6.Is(are)the well(s):Vermaneat or Effemparary 90dare of C&;Ued Well Coutactor; Date
By signing thisfarm,1hereby certify that the wells)was(were)constructed in accordance with
7.is this a repair to an existing well: Dyes or �To 15ANCAC 02C.0100 orl5AJVCACO2C.0200;Yell CanstructionMandards and that o copy
ythisfsa repair,fdlout(mown well construction information and explain the nature of the of this record has beenprovided to the'Well 0W17eT.
repair under f21 remarks section aronthe back of this form. 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 I GVjTI is needed, Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:, 24.SUBMITTAL INSTRUCT-IONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 day s of well completion per the following:
For multiple wells list all depths jfdffierent(example-3@200'and 2@100D
n' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.static water leybl below top of casing.-. (ft.) Information Processing Unit 1617 MSQ,Raleigh,NC 27699-1617
lfwater level is above casing,use
Bit Off: 24b.For Irkiection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: C- (in.) Prograrn,1636 MSC,Raleigh,NC!27699-1636
AIR ROTARY 1
12.Weil construction method: 24c.For Water Supply and Open-Loop Geothermal Return Copy to the
(i.e.auger,rotary,cablo,direct push,etc.) county environmental health departmenti of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing r over 100,000 G.PD:Copy to DWI,CCPCUA
-1611
13R.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh.,NC 27699
13b.Disinfection type: 701/aHTH Amount: Oz DATE SITE VISITED: z
Pri(-e- VISITED BY: G0 Jr j..5-2-
Forin GW-1 North Carolina Department of Environmental Quality-Division of WaterResources Revised 6-6-2018