GW1-2022-08851_Well Construction - GW1_20220912

'b"V1Ed L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1°Well Contractor Informntion:
V)` 14.WATER ZONES
Weli Contractor Name FROM TO DESC ON
2-1 a
tt
ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING for multi-used wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TRICKNESS MATERIAL
fL R i in.
Company Name _
! O-SD
16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: (J FROM TO DIAMETER THICICMS T'fATERLIL
List all applicable well construction permits(i.e.TIIC,County,State,Tlarlanee,etc.) ft. PL ft. v` m.
3.Well Use(check well use): ft• ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICIMSS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/COoling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1Be GROUT
❑Irri ation ❑Wells>100,000 GPD FROld I TO MATERIAL. EMPLACEMENT AIETSOD&AMOUNT
Non-Water Supply well: tt, ft. Qe-Nom Uat+ 0
❑Mondtoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK(if a liable)
❑Aquifer Storage and Recovery L'Sdinity Barrier FROM TO MATERIAL E LACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑E erimental Technology ❑Subsidence Control
re0thermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
M
❑Geothermal(Heating/Cooling Rettun) ❑Other(explain under 421 Remarks FRO TO
ft. DESCRIPTION(color,hardnws,soitlroek nio sae,ete.k. D 4
4.Date Well(s)Completed: ��S a7' Wen ID# ft. 0 ft.OMP
O / Yot►'o
5a.Well Location: Phone #1?7 -C�/ ff'F-7 ft. ft.�3
J _6 y �"
Facility/OwnerNameT Facility M9(if applicable.) ft. ft Y 4=^ -s �y x-- -
c RA ski q � ft. ft. S r F 1 2 2022 _
Physical Address,City,and Zip ft ft'
21.REMARKS
County Parcel IdentificationNo.(PIN) BORES DEPTH (� JV4
County t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( I ) DIA OF LOOPS(P)
(ifwell field,one lat/longis sufficient) 22.Certification: SDR OF LOOPS
N w
6.Is(are)the well(s): aermauent or ❑Temporary Si re of Ce ed ell Contractor Date
By signing thisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repairto an existing well: ❑Yes or BNo 15A NC.4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction b formation and explain the nature of the of this record has been provided to the well owner.
repair under 021 remarks section or on the back ofthisform.
23.Site diagram or additional well details:
ti.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
constnic onLr-- -1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ifdfferent(example-3©200'and 2©100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ff) Information Processing Unit,161'7 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" ,
i
11.Borehole diameter: (in.) Bit Off: 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
(i.e.auger,rotary,cable,direct pusb,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
13a.Yield m 3 Method of test: it fa/1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP ) � ',
13b.Disinfection type: 70%HTH Amount: 0Z DATE SITE VISITED:
I
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VISITED BY:
Pri t-P•
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018