GW1-2022-08534_Well Construction - GW1_20220513

W I,l` i+CCNS'!1RUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor lnformntion: '
l_f r`L �,— a*1.1-3 14.WATER ZONES f '+
Well Contractor Name 1 PROM TO DESCRIPTION
. waft. � �
NC Well Contractor Certification Number MOIL 2 10 ft
15,OUTERCASING formula-rased wells ORLU Ha licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TIi1CKNEss MATERIAL
ft tt. I in.
Company Name 'r 3 �
Frt��e b 9 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: 0y4 e�rl,s' ���` rbr& ' FROM TO DIAMEITR THICIGMS I 11fATMUAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc) ft. r a 3 ft !/ t 8 in. so pat P Vt` r
3.Well Use(checkwell use): ft ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLAT SIZE THICIONESS MATERIAL
❑Agricultural ❑Municipal/P.ublic ft. ft.
❑Geothermal(Heating/Cooling Supply) te&sidelnial Water Supply(single) ft ft. ;,,•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT D
[Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&.AMOUNT �T
Non-Water Supply Well: ft. S f1 /V'pk Pt-5 96 V re4 JOD
❑Monitoring ❑Recovery S IL 2 ft. a-w-k(,rot! P Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater RemediationI9.SAND/GRAVEL PACK d a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENTMETH❑Aquifer Test ❑StormwaterDrainage ft. ft❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
❑Geothermal(Heats ng/CoolingRetum) ❑Other(explain under#21 Remado) FROM To DESCRIPTION color,hardaess,suVrnck sia eea
D ft. ^ f•1 Soil
4.Date Wel](s)Completed: � 3412"2veu W# �R�_ •11 S f- 2 2Z ft6rdkei.,
Sa.Well Location: Phone # y �yv �y ft fL
9 "�L 0 ft ft
Jr�a�c�k—olylet (}i
MAY 1
Fancility/O/wnerNamn'e / //{� Facility ID#(-if-�Wliccaable) (1�fA��91EN1
f ft ft
21® lL —Lyles ��tl��®e1 �� �����V�l � ft ft { W (111{[6gtQ
PhysicaI Address,�i.andn f Yft' '
C
21.REMARKS` O
county Parcel Identification No.(PIN) 13 e.0{ J `-- Qdck Feow, 190 ' 11 U
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlongis sufficient) 22.Certification:
3f , 07634 N 9do 6S,3S'2, W
6.Is(are)the well(s): permanent or ❑Temporary sipaturt of Certi:Eltd Well Contractor Date (Cy
By signing this form,I hereby certify that the wells)was(were)constructed in accordmrce with v
7.Is this a repair to an existing well: ❑Yes or 5roo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a dopy
Ifthis it a repair,fill out]mown well construction information and erplain 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 cons tructiois ibfo
construction,only 1 OW-16is needed. Indicate TOTAL NUMBER of wells (add See Over'in Rematiss Box).You may also attach additional pages ifneeessary.
drilled: ! 24.SUBMITTAL INSTRUCTIONS
1-Total well depth below land surface:
FW)Vulliple wells list all depths jdiierent(crumple-3(a)200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following: -�
a� 24a. For All Wells: Original form to Division of Water Resources(DWR), g
,10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617-
`Ifwater level is above casing,use
Bit Off: .O 119 24b.For Injection Wells. Copy to DWI;,Underground Injection Contivl(IUC) Q
11.Borehole diameter: (m•) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY IIt "y
12.Well construction method: 24c.For Water Supply and Open hoop Geothermal Return Wells:Copyto the
(Lt.auger,rotary cable,direct push,etc) county environmental health department of the county where installed .
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 40 Method of test: A.Ile" Permit Program I611 MSC,Raleigh,NC 27699-I611
! !
13b.Disinfection type: 70%HTH Amount- OZ DATE SITE VISITED:`tLourlk�>
Lim'•�'':D�
VISITED BY: 3 Z7 2L