GW1-2022-08515_Well Construction - GW1_20220513

S R UCTIOYR EiCOR dZ4W ;For Internal Use Only; j
1.WeJI Contractor Informntion:
wrlv Ids
14:W ATER ZONES l ,
tin 1A TO DFSCRVnON
Well Contractor Name ! o ft. y�2 ft. tl '
710o 7 A
a s 7a.A ft. ft
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased wells ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM I To I DIAMETER I THICKNESS I MATERIAL
7� `�(( cq _ ft. It ! in.
Company Name 1(cU k,,, j°-Ll d `' /�/��^ I(,n� 16.R MER CASING OR TUBING(geothermal closed loo
2.Well Construction Permit Q 1 -6 V(t 2-0g FROM TO I DIAMETER TILICICRES NfATERLIL
List all applicable well construction permfts(i,e.WC,County,State,Variance,eta) I ft. /,5/ ft 6.11S in• R 01 P UL
3.Well Use(check well use): ft ft. m.
Water Supply Well: IrR SCRI?TI
TO FROM DIAMETER SLOT SIZE TS[CLQtESS MATERIAL
❑Agricultural ❑�Municipal/Public ft. ft. in.
❑ ve
Geothermal(Heating(CooIing Supply) "'sidcntial Water Supply(single) ft I ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
ElIrrigation ❑Wells>100,000 GPD FROM TO I MMATERIAL. I EMPLACEMENTMETHOD&AMOITNT
Non-Water Supply Well: ft. 9Xft' B��=elt +� a��c•/
❑Monitoring ❑Recovery ft ft.
Injection Well: g, g•
❑Aquifer Recharge ❑GroundwatrxRemediation 19 SANDIGRAVELPACK rifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METH OD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
eta
❑Geothermal(Heating/CoolingBetmmm) ❑Other(explain under#21 Remamic5) FROM TO DRSUIPSIONcolor,hardaess,saiLtracictypct grmin siu
p � 37 '� o:L �•�u40
4.Date Wells)Completed: '�2 Well ID#AA PO aS �.77 ft �Vr.K D
Phone # 3� `S-11 ?091 ly,- K S2° ft A. , r �,►,.
5a.Well Location: -� i
ft ft.
Fadhty/Owner Name' ft.Facility ft ft.
ft
MAY 1
i q 20 tf,%k 1tV' M, `t.LK,0%a,L�.. ft
Physical Address,City,and Zip ft fti ItlfOffl^+Ot/Dn QA39G atg Unit
�/ t 21.REAL4RKS
14 A KI r J�" /y6 �S••� .S. v dj, vc� �
county Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -f I q3' �� �� )t r�sef
(ifwell field,one lat/longiiss sufficient) 22.Certification:
/
3 b i to 0 3 1 N Q. T-92R9W � �p dd22,
6.Is(are)the well(s): permanent or ❑Temporary Si01ire of Ceriffied Well Contactor Date
By signing thisform,1hereby cer*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eadsting well: ❑Yes or 36o 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
1f this is a repair,fill out)mown well construction informattan and o plain the native of the of this record has been provided to the well owner.
repair under#21 remarks section or an the back ofthisform. 23,Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal We.Ils ha%ing the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
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 lfdff Trent(example-3(a)200'and 2Q100D i
30' (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levhJ below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Jf water level is above casing use"+"
Bit Off: S-943 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
ti 11:Borehole diameter: (�•) 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 dep'arttiment of the county where Installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producin over 100,000 GPD:Copy to DWR,CCPCUA
8 Q, Permit Progmrn,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i !!`� J j
0%HTH 7 0 OZ DATE SITE VISITED.-_(P 2 Z2
13b.Disinfection type: Amount: v�� ' �.
VISITED BY:
'Pri cry-- —
Form GW-1 I nmental Quality-Division of Water Resources Revised 6-6-2018