GW1-2022-08847_Well Construction - GW1_20220912

a CONSTRUCTION TIFeUCTION RECORD (G'VV-1) For Internal Use Only:
1,Well Contractor Inforriation:
Jerc)l wkl��1.n5 _ 14.WATER ZONES
Well Contractor Name FROM TO DESCRUTION
53 A ft Li 212 ft. /Z am
ft. &00 It I/L GPIVA
NC Well contractor Certification Number a
15.OUTER CASING-(for niulti-cased Wells ORLTNFR da livable
YADKIN WELL COMPANY,INC, FROM TO �LMMETER Tffi�Ta & MATERIAL
ft ft in.
Company Name /l l 26.INNER CASING OR TUBING eoiheronal closed-loop)
2.Well Construction Permit#: l ��l f -3 FROM FTO I DIAl4ILTER I THICKNESS I MATERIAL
List all applicable well construction permits ri a.UIC,County,State,Variance,str-) 1 ft '�'jit Vr.S®q in. , 'Og /Y 1 y
3,Well Use(check well use): ft ft. in. apt o
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICIOYESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) - ft. ft. in.
❑Industrial/Comrnercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMMT114ETHOD&AMOUNT -�
Noa-Water Supply Well: ( ft 3
❑Monitoring ❑Recovery 3 ft ,3 ft. G -Ck.
Injection Well: O
ft ft
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVEL PACK(if applicable
)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL. EXPLACEMENTry=OD
❑Aquifer Test ❑Storrawater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLIl4GLOG faUmch additional sheets if necessary)
❑Geothermal(Ileatmg/CoolingRettmi) ❑Other(explain under Remarks) FROM TO DESCRmTSON mlar,hardness,salYrark a sae,ete
a d ft. 130 ft- p (!
4.Date Well(s)Completed: O 3I I aZ WellID9_.'&P--14 0 .
130 ft 60LI It (rar cle
5a.WellLocation: Phone# ft. ftr 7
Y'ew T>rv'd`�'G! G✓1/C/ey ftft. ..-_�`°-- �`n• `
Facility/Owner Name Facility ID#(if appli�}ble)„ �C N ft ft S t P I 2 Z 2
Physical Address,City,and Zip ft ft
21.REMARKS }L
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,onelat/longissufficient) 22.Certifeation•
7� N �l �� 3 C'.8�' w - �`31 JJ L
6.Is(are)the well(s):'1Permanent or ❑Temporary Siguatuf of C ed Well Contractor .Date
By signing thisform,I hereby certi)ry that the well(s)was(were)constructed In accordmrce with
7.Is this a repair to an Qdsting well: ❑Yes or @T0 15ANCAC 02C.0100 or 15ANCAC 01C.0200 Will Construction Standards and that a ropy
Ifihis u 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 i21 remarkr section or on the back of this form.
23.Site diagram or additional well details:
8.For Geop'robe/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 1 is j 4z,
needed Indicate TOTAL NUMBER of wells (add'See Over'in Remadm Box).You may also attach additional pages if necessary.
drilled: 24.SUBAffITAL INSTRUCTIONS Q
9.Total well depth below land surface: /00 (ft)
For multiple wells list all depths!f different(example-3@200'and 2Q1001 Submit this GW-1 within 30 days of well completion per the following:
too 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Infbmlation Processing Unit 1617 MSC,Raleigh,NC 27699-1617 `
Ifwater level is above casing,use"+'
if Borehole diameter (in-) Bit Off: i�yO 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 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
13s.Yield(gpm) Method of test: Q /�!/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
p1
70%HTH 0Z DATE SITE VISITED:
13b.Disinfection type: Amount: �3
pry L VISITED BY:
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