GW1-2022-08595_Well Construction - GW1_20220411

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fCQNS TTRUCTLI N RECORDLGW-11) For Internal Use Only:
1.Well Contractor In-formation: .}
Y /y /, b Y 14.WATER?ANES
Well ContractorfNanic ' _ FROM ro DESCRIP-nON
APR 1 � 9 ft. �tre �• S.nq / �-'rav�,'�� �
�57a-A 5 ft. ft
NC Well Contractor Certification Number : ^• �,
•�! . �' 15.OUTER CASING for multi-used wells)ORLINER tf a livable
YADKIN WELL COMPANY,INC. 1;". ';'!r^'1' A l FROM To DL M TER Tffic.ZavEss MATERL&L
ft. ft. � in.
Company Name
3 4� 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DWWrER THICIOCS5 MATERIAL
Llsf all applicable well construction prr•tnils(I.e.IIIC,County,State,Variance,ett) ft �' O /• �in.
3.Well Use(checkweli use): ft. ft. in.
SCREEN
Water Supply Well: 1rRO1%1 TO DIAMETriR SLOT SIZE THILHmss MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g• ft. in.
❑Industrial/COmmeIcial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D It, ft. P� �`�• dvrYd
❑Monitoring ❑Recovery l� IL 3-C//• fl.
Injection Well: ft. % A—
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK rf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENTI Af , NT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRMLING LOG fattach additional sheets if necessa
❑Geothermal(Heating/Cooling Rehnn) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION valor,hardness,mlvrork 'e size,etc.
O ft.
4.Date Well(a)Completed: ' Well ID# (LS�Z s ft- soft.ft
/�Jr!� �v �rr•+�rP
Sa.Well Location: P Hone # "7,ay. 3 .4 ft y°3 �''� �� °� �rQ"'•.
�/ et1 frL,A�cr �4 vsc a Nt ��e� 76 q ei ft.
fL
Facility/Owner Name Facility]DA fapplicable) it. ft
J
�Z �•Ft K v y. ,L.n Gv_ Tcf�l-' a1 �� ft. ft
ft &
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No.(FQI) w- A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
I
42' N T*( 36 !rZ 3 Z w s 'V.)2
Si
6.Is(are)the well(s): *rmanent or ❑Temporary
of C ed Well Contractor Date
By signing thisform,1hereby certyy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eldsting Well: ❑Yes or 0No 15A•NCAC 02C.0100 or 15A NCACV2C.0200 Well Construction Standards and that a copy
1J1his is a repair,fill out known well construction information and explain the nature of the of this 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 OW-1 is needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
I
drilled:• 24.SUBMa-1—AL INSTRUCTIONS
9.Total well depth below land surface:. (ft
)
For multiple wells list all depths lfdifferent(example-3 100 d2Q100D • Submit this GW-1 within 30 days of well completion per the following:
2 24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: Uf7 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+" /
Bit Off: !O• 24b.For I[ iection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in-) Program,1636 MSC,Raleigh,NCI 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 department of the county where installed
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) I i�l Method of test: L1Y / 1 ��J*
13b.Disinfection type: 70%HTH Amount: (�0 OZ DATE SITE VISITED: G t% �G'��
IStTEr BY: �
1� t
..,v, ij_4i,rim Rnn nl nhment nfFnvirnnmenfal niinvty-nivisinn of Water Remurces Revised 6-6-2018