GW1-2022-08454_Well Construction - GW1_20220513

d 11 CONSTRUCTION RECORD(GIVE-11 For Internal Use Only:
I.Well Contractor Informntion:
�t'f C N C�A'�I� ��►S 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name ft t 3o ft. 9
a g sa A ft. ft-
NC Well Contractor Certi{icadonNumber 15.OUTER CASING formulti-cased wells)ORLTNER da livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCIOVEss MATERIAL. i
(� ft ft � in.
Company Name Yadkt 336- r 7 "����
1 r� 16.IINIIVER CASTING OR TUBING 'eothermal dosed-loop)
2.Well Construction Permit#:eels M C' o( '2 2 ��D-7Zo 21 FROM TO DT&M11-rFR I TMCICNEss MATURaM
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc.) 41 tt 1 4 ft to V#; in. Spool �e. (�
3.Well Use(check well use): v ft' `n•
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOT SIZE T)MOCYEss MATERIAL' V'
❑Agricultural ❑ptclpal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) iliResidential Water Supply(single) ft tt
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO r"TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. y 14 It. Pl t` IPti
❑Monitoring ❑Recovery ft. 'L R• �t ere Ge d 1
Injection Well:
ft fL
,OAquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK Cifa livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier mom TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑St nnwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed loop) ❑Tracer 20.DRMLINGLOG attach additional sheets if nececsa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIIMON carer,nardncn,:oiY-rk .• sae,etc
d ft. ` tt. �-
` � �7�5-
4.Date Well(s)Complete.. 3 �3 Well m# (� ,a Ar
5a.Well Location: Phone 12,C1
ft R
t r e
Facility/Owner Name Facility 1D#(if applicable) ft. ft
l LJ
7.3 8 C'.d '�� r ft. ft.
Physii at Address,City,and 202
k a
f21.REMARKS
t
Co' Parcel Identification No.(PIN) � �u� �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lattlongis sufficient) 22.Certification:
�° SP " N 8blo .act� 3 7" w roG t3
fi
6.Is(are)the well(s): aermanent or ❑Temporary Sign' a of ' eel Well Contractor' Date
/ By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.-Is this a repair to an existing well: . ❑Yes or 040 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJthis is a repair,fell out]mown well construction information and explain the nature of the ofthis recordhas been provided to the well owner.
repair under#21 remarks section or on the 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remadcs Box).You may also attach additional pages if necessary.
dulled: / 24.SUBMITTAL INSTRUCT16NS
9.Total well depth below land surface: `� ( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiierent(imample-3@200'and 2@1001 ,ter
24a. For All Wells: Original form to Division of Water Resources (DWR), y
10.Static water level below top of casing: 50 (ft.) ,
Ifwoter level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 Q
j> Bit Off: . lot) 24b.For Injection Wells: Copy;to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NO 27699-1636
AIR ROTARY g is
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
.y A,( Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) r Method of test:
13b.Disinfection type:
70%HTH Amount: 16 OZ DATE SITE VISITED:! `�0 "7-7-
Pri nP- _ VISITED BY: