GW1-2022-08472_Well Construction - GW1_20220408

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CONSTRUCTION CTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
/t!A 14.WATER ZONES I.
ON
FROM TO DESCRIPTI -
Well Contractor Name A ti it Z L !l/
1.
3 v 3 6 A a fr. s,s
NC Well Contractor Certification Number 15.OUTER CASING for multi-ca wells ORLWER rf a livable
YADKIN WELL COMPANY,INC. FROM DIAII�TER THIGTINEss MATERW
ft lin.
Company Name �'l
j'1� 3�-' �� � 16.II%'iER CASING ORTUBING 'eothermalclosed-loo
2.Well Construction Permit#: K%�,"� 'O I a®!®- 2® FROM I TO DWTrrFrt I THICKNM- S I MATERIAL
List all applicable well construction permits fl e.UIC,County,State,Variance,etc.) + I fr• 6 ft. j/ in.
o /r
3.Well Use(check well use): fr. fr. inn
Water Supply Well: 17.SCREEN �J
FROM TO DIAMETER SLOT SIZE TIIICIINES5 MATERIAL
❑Agricultural ❑�MJunicipal/Public ft. in•
❑Geothermal(Heating/Cooling Supply) [pResidential Water Supply(single) ft. i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. is G,ra vi YZ
❑Monitoring ❑Recovery 3 ft. Air, 6 n!
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ffappliSable . t
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMFLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEscRnnTox cams,hardness,aoivroek a aiu size,etr
® ft.
4.Date Well(s)Completed: ' 2� Well m#A ho- ft. J ft M
5a.Well Location: Phone # �o� -���J'� `�� fL W 10 ft ex 11 i+
F
�a
pcility/6 er Name f. /� -, Facility ID#(if applicable) - �4 a " tA_ ♦
J r t ran!
G 3 p d UP,U l / PK& V��E!0 �� ��• ft. ft.
Physical Address,City,and Zip fr. ft
t Jd k1,-t 21.RETSARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification' 1 l v N W Z .2,
6.Is(are)the well(s): 110Permanent or ❑Temporary Sifnature of Certified Well Contractor j 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 l�No 15A NCAC 02C.0100 or 15A 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 ofthis record has 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 1 GW]�is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: /t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths if different(example-3@200'and 2©1001 Submit this GW-1 within 30 day of well completion per the following:
24a. For All Wells: Original.form to Division of Water Resources (DWR),
10.Static water level below top of casing: y (ft.) Information Processing Unit,1617�MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+' '
11.Borehole diameter: (in.) Bit Off: . -1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC121699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Operi-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depa tm;ent of the county where installed
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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
13a.Yield(gpm) Method of test: ��y LI+r
13b.Disinfection type: 70%HTH Amount: �� OZ DATE SITE VISITED:A7 2-2 � @✓'^4�
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