GW1-2022-08849_Well Construction - GW1_20220912

COIYS TRIfJC 1^1ION RE COR (GW-1) For Internal Use Only:
' 1.V✓ell Contractor Information: ( �m
, eg j wQTIC I+�S 14.WATER TONES
Well Contractor Name FROM TO DESCRIPTION
ft. 970 ft,
�-{S1A &
NC Well Contractor CartificationNumber 15.OUTER CING 11or nvD]ti-rased we➢s RLRfavable
YADKIN WEL COMPANY,INC. FROM ffis
MATERIAL
ft. ft. in.
Company Name
Q/ 16.IN11ZER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: `(y�p Y FxoM TO D7AnrrruR rHICIpINEss Hv.TERIAL On
List all applicable well construction perriinits(r.e,UTC,County,State,Variance,etc) ft `ge:� it L�� in• ®8 G T)v
3.Well Use(checkwell use): ft. ft. 'a in.
REE N
Water Supply Well: FRA TO DIAmErER SLOT SIZE TMOCNESS MATERIAL
❑Agricultural ❑MunioipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) . t}• ft. in.
❑IndustriaUCommercial []Residential Water Supply(shared) 1B.GROUT
❑IlTigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. S ft. NO Ic f1w, Po r'J J Cp
❑Monitoring ❑Recovery .S ft a:) ft- k P
Injection Well: Ie
ft ffi
❑Aquifer Recharge []Groundwater Remediation
I9.5AND/GRAVEL PACK rf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. E1%TPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20. LOG attach additional sheetsifnecessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIMON valor,hardness,sojVrccktypc. sue,ete
g /J D ft. 0 ft 5-0,rtl
4.Date Well(s)Completed: 8 !0I Z Well ID# � r ` -70 fL 1003 ft- G reed.l
5a.Well Location. �':, Phone # GC9'f 3f'33LC� & fL
f9hG!~ ^i eOe7/ , �r.7<<es ft ft - -_ ;
Facility/OwnerName/ G F ID#Crfspplicable) ft ft
Physical Address,City,and Zip
ft ft.
21.REMARKR
County Parcel Identi£cationNo.cmi)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
6.Is(are)the weli(s): Oermanent or ❑Temporary Signatni of CoxtErd Well Contractor Date
By signing thisform,I hereby cen)fy that the wel(i was(were)constructed in accar&mce with
7.Is this a repair to an existing well: ❑Yes or *D ISANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,,ldl oui known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.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 C7W 1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlo;Box).You may also attach additional pages if necessary.
drilled: ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l n o 3 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Jfdierent(example-3Q200'and2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ieve]below top of casing: S� (ft. Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
Tfwater level Is above casing,use"+"
11.Borehole diameter. (in.) Bit Off- D�� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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
(to.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 l
13a.Yield(gpm) Z Method of test:
13b.Disinfection type: 70%HTH Amount 3-I OZ DATE SITE VISITED: /�