GW1-2022-08579_Well Construction - GW1_20220513

M1jjEf'NS i7'JRUC1TION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
f "b lC -4 L AIW ���r1A/� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3�3 q- _ft. ft. 7 .r3 r Wv
ft. Cft
NC Well Contractor Certification Number �36� fo I'
15.OUTER CASING for multi-eased wells ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TffiCKNESS MATERIAL
ft. j in. .
Company Name v �I µ ��, ��— `Z ® '
G 16.IlNNER CASTING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:&j5 AAF^ OI 1(f.30 _.202.k FROM TO DIAM TER TMCICCNMMs MATERIAL
List all applicable well construction parks(4e.f1IC,County,State,Yariance,etc) ' ft. 30 R �t/LJ in. S ) ev L
3.Well Use(check well use): ft' 1J ft. in.
Water Supply Well-, 17.FROM�ErT0 DIAMETER SLOT SIM- 7,111cla Lss MATERIAL
❑Agricultural ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 1s.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I To MATERIAL EMPLACEMENT METHOD 5,AMOUNT
Non-Water Supply Well: , ft. ft. �' 3
❑Monitoring ❑Recovery ft -7L/ ft.
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemedration 19 SAND/GRAVEL PACK da liable)
❑Aquifer Storage and Recovery ❑S&Udty Barrier FROM To MATERIAL EMPLACEMENTN=OD
❑Aquifer Test ❑Stormwater Drainage & ft
❑Experimental Technology ❑Subsidence Control it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifneeessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM xo DESCRIPTION color,hardness,seiVroc& sve etc
ft �0
4.Date Well(s)Completed: —2 Z WellID#AA4— 9-7 r 1 7 ft' 1130 ft y PCjr�w
Sa.. fWLellLocation-
. Phone # 331�. .Q q3 ft Y'10 ft .4 V�anrLf
0 Z R 1&ravt/Tv
Factlity/OwnerName Facility ID#(If applicable)
�/ ft. ft
35 l�oht
+1�
Physical Address,City,an lap ft ft
N► r'
v 2L REMARKS
( ��I LL % 6if _
�. o rctcv�.Ya
County Parcel Identification No.(PIN) th/ r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36 , 11/.S(/ N 90 e 7 -7 3 3 L/ W
6.Is(are)the well(s):*ermauent or ❑Temporary Si atnre of Certified Well Contractor,-- n ProceG ltl Ur*Daft
BY signing thisform,1 hereby ce at th Jere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )QIo 1 SA NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out]mown well construction information and explain the nature of the of this record has beenprovided to the well owner.
repair under#21 remarks section or on the back oft his farm. 23.Site diagram or additional well details:
S.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 GW-1 is needed. ladicata TOTAL NUMBER of wells (add See Over'in Remadcs Box).You may also attach additional pages ifnecessmy. —.•
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: o 2' (ft') Submit this GW-1 within 30 day s of well completion per the following:
For multiple wells list all depths tfdifjerent(example-3Qa 200'and 2®100� +�
10.Static water level below top of casing: (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR), f1!
Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617n,
Ifwater level Is above casing,use
11.Borehole diameter: (� m Bit Off: 6, V 24b.For IrCiection Wells: Copy to DWR,Underground Injection Control(IUC)
( ) Program,1636 MSC,Raleigh,NC1,27699-1636
AIR ROTARY i n
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the VJ
(it.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinK"over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: re' k
13b.Disinfection type: 70%HTH Amount: Z OZ DATE SITE VISITED:
Pei r-a
VISITED BY: