GW1-2022-08852_Well Construction - GW1_20220912

S
WELL+CONS lTih"I( CT1ION R+'C'ORD(GW-1) For Internal Use Only:
1.Well Contractor Informntion: !
/ r 0 l,`S 14.WATER ZONES I
Well Contractor Nam FROhf TO DESCRIPTION
'ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-used ivells OR LIVER if a licable
YADKIN WELL COMPANY,INC. PROM To DIAMETER THICETIFSs MATER AL
ft. ft. f in.
Company Name
/,I 16.INNER CASING OR TUBING eothermal closed-loop)
SV
2.Well Construction Permit#: wy V �D FROM To DIAMETER I THIC1C?ZSS MATERIAL
List all applicable well construction pu7nils(i.e.UIC,County,State,irarlance,etc) fr• *2„• ft. Q 1 n. Cr3.Well Use(check well use): ft. Jl/ ft.
4 in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic A. ff. in.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. () fr. � �• �U�»
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
❑Aquifer Storage and Recovery C'Salinity Barrier FROM To MATERIAL EMPI ACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑E erimental Teclulology ❑Subsidence Control
eothermal(Closed Loop) ❑Tracer 20.DRILLING LOG fatt2ch additional sheets if necessa
FROM TO DESCRIPTION color,hardness soil rock Fin she,etc.
Remarks
❑Geothermal(Heating/Cooling Retiun) ❑Other(explain under#21 Rems
Q ft. ft. ;L
4.Date Well(s)Completed: '0`22--' Well ID# A A v as' ft. Si ft. /� t s
Sa.Well Location: Phone # 7�_l;�� G��-] ft. ft.
!1 ft. ft. � a'.�i� �
Faclkty/Owner Name Facility M#(if applicable) ft. ft ' ' 1
ft. fr. SEP 1 2 nizz
Physical Address,City,and Zip ft ft t
21.REMARKS
CountyParcel Identification No.(PIN) BORES DEPTH
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: # LOOPS PER BORE ( ( ) DIA OF LOOPS ( )
(ifwell field,one lat/loagis sufficieot) 22.Certification: SDR OF LOOPS
_J N W ���..aIp3L
6.Is(are)the well(s): Wermaueut or ❑Temporary 5i re of C ed W Contractor Date
i
Bysigning thisform,I hereby certjry that the wells)was(Mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1fThis 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 t•'+is form.
23.Site diagram or additional well details:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells baying the same You may use the back of this page to provide additional well construction info
constnic on -1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:y gr 0 24.SU131VIITTAL INSTRUCTIONS
9.Total well depth below land surface: 3,740 (ft) Submit this GW-1 within 30 da s of well completion per the following:
For multiple wells list all depths if different(example-3(n)200'and 2©100) y P P g:
24a. For All Wells: Original;form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699/1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction Illeth0d: 24c.For Water Supply and Open-Loop Geothermal Return Welts: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 producint over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70°/n HTH Amount: OZ DATE SITE VISITED:
I
pT'l rP_' _
VISITED BY:
Form GWA North Carolina Department of Environmental Quality-Division of Water Resouices Revised 6-6-2018