GW1-2022-08853_Well Construction - GW1_20220912

WELL L CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
t
14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
��,a .� b mot. f ft. s
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-used weus ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TMCKNESs MATERIAL
ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal rlosed-Igo
2.Well Construction Permit#: W�O�D ) I V I FROM TO DIAMETER TffiC(tNFSS TtATERIAI
List all applicable well construction permits fl.e.UIC,County,State,Yar/ance,eta)
3.Well Use(check well use): ft. ft' in.
17.SCREEN
Water Supply Well:
I71051 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑G'eothmmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
3 ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (t. it. a
��hc�iwt t:M►
❑Morlitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery C'Salinity Barrier FROM To I MATERIAL I EII7PIACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑E erimental Technology ❑Subsidence Control ft. it
e0thermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if uecessa
FROM TO DESCRIPTION color,hordners soilfrock ninsrse eta
❑Geothermal(Heating/COolingRetum) ❑Other(ex lain under#21 Remarks O ft. ft. e 1
4.Date Well(s)Completed: T-9`sy Wel1ID# trn^ it ft
5a.Well Location: Phone # -7 ft ft
oa y�S ft. fL e ,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
-7 DVI P—a ��� �, fit. ft. SEP i -2 2022
Physical Address,City,and Zip fL ft
fill?J.K e.
21.REMARKS tv V° `
County Parcel IdentifrcationNo.(PIN) BORES DEPTH (*'MXSZ
5b.•Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( ( ) DIA OF LOOPS( )
(if well field,one lat/longis sufficient) 22.Certification: �DSDR OF LOOPS
6.Is(are)the well(s): Qermauent or ❑Temporary $i ature ofrCertified/Well Contractor Date o C
By signing thlsform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair'to an existing well: ❑Yes or P1No 15A NCAC 02C.0100 or 15A NCAC;02C.0200 Well Construction Standards and that a copy
if this 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 021 remarks section or on the back of this form.
23.Site diagram or additional well details: C
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
construct onl�el�G,J-1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarks Box).You may also attach additional pages if necessary. C
drilled: �S,j p 24•SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: %..f lJ (ft.)
For multiple wells list all depths If different(example-3©200'and 2©100D 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 tap of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater 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
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
TOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci€Wover 100,000 GPD:Copy to DWR,CCPCUA
m
13a.Yield
(gp ) 3 Method of test: �. �`� Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
Pr i
VISITED BY:
r�P- - - - '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019