GW1-2022-08448_Well Construction - GW1_20220513

i ,"rCy�I�t�TR UCTION RE COR (GW-1) For Internal Use Only:
1.Well Contractor Information:
BrV W/l 14.WATER ZONES
Well Contractor Name FrtOM TO DESCRVnON
3�3 b IVft. . a �t' }S(�G�e G rb^•'!•' ��2(� �t,
NC Well Contactor Certification Number 33'I 3,37 't )(4re, 1&a-4-
15.OUTER CASING for n ulfi-cased w!lls ORLINER d a lieable 3�p,
YADKIN WELL COMPANY,INC. PROM To DIAMETER' THICKNESS MMIRrAL
ft. � .
Company Name e ���,i '
PIN/
]n ^ y 16.IlVIVER CASING OR TUBING eothernral closed-too
2.Well Construet*on Permit#: T KW L A 8 12 0 O 3(� / >�oI TO DrAM4i THIcraVEss nuTERraI Q
List all applicable well construction permits(Le.Wa County,State,Variance,etc) / ft [� ft G fly' in. SAW cil� vc,
3.Well Use(checkwell use): ft. J f' 'n' f��
1T.SCREEN ?��
Water Supply Well: FROM To DIAMETER SLOT SIZE.-•THICHNESS MATERIAL
❑Agricultural ❑ icipal/Public ft. t, In
❑Geothermal( ea Coolin Supply) sidential Water SuPP1Y(single) .
�!JC
n.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑We PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply Well: Q ft. Gi ft. (-
❑Monitoring ❑Recove 422 ft. 4.3
Injection Well: MJAI ft
❑Aquifer Recharge ❑OroundwstgRer %g Uri
,,,����ppn 19.SAND/GRAVEL PACK der licable)
❑Aquifer Storage and Recovery ❑SaJ*%!i 4CVS0G FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft /
❑Experimental Technology ❑Subsidence Control it.
❑Geothermal(Closed Loop) ❑Tracer Z .DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION rotor,hardness:oVrock .' sce,etc
ft. -Z ft. ,S'' �/
L� a
4.Date Wells)Completed: S'�^ ra�' Well ID# '�, ft' S- ft s' .
�y t� �
5a.Well Location: Phone # 7�®e�.�e��73 '•� f ti.rr
Fac7ity/OwnerName Facility IDO(ifapplicable) ��f f.ft "AL
f�'t,: e 262 Si ( e o yr (00 � aC �� 4or
Physical Add=&,City,and Zip y�Q ft y'70 f• )Vora" ajr+ �2n•7� t
scd,
County Parcel Identification No.(PIN)
ITV5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d '�1^' �•t a(o�"7 01
(ifwell field,one lat(loagis sufficient) 22.Certification:
j�4e�Z; � 5-
6.Is(are)the well(s): CgYermanent or ❑Temporary Signature of Certified Well Contractor Date 0,
_� By signing thisform,I tify hereby cer that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or M40 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WHI Construction Standards and that a copy Q
1f this is a repair,fal out known well construction b1formation and explain the nature of the of Phis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisfa m.
23.Site diagram or additionalwell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well construction imb
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in RemariZ Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -70 Zs -(ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths 1fdifferent(example-3@200'and 2®1001 P
v t 242. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: (ft-) Information Processing Unit,160 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter (i.•) 131t Off: .970 24b.For Injection Wells: Copy to DV R,Underground Injection Control(IUC)
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,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Lj/ ` Permit Program,1611 MSC,Raleigh,NC 27699-1611 t
13s.Yield(gpm) / �Z Method of test: r� R r ?0 7 ®a
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
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i VISITED BY:- hg�