GW1-2022-08855_Well Construction - GW1_20220912

W 4'LL CONSTRUCTION REC-ORID (GW-1) For Internal Use Only: I
0Weil Contractor Informntion: {
� 14.WATER ZONES !, :
FROM TO DESCRIPTION
We ontract0r me
ft. ft. /
NC Well Contractor CertiS'on Number 15.OUTER CASING for multi-cased ORLDVER if licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICICJ•iEss MATERIAL
k. ft. in.
Company Name (—p
O�U I )h 16.INNER CASING OR TUBING(geothermal closed-loop)
wl
2.Well Construction Permit#: lJ FROM To DIAMETER THICIINFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,1"ariance,etc.) ft. ft. 0'i
3.Well Use(check well use) it• fr. in.
:
]7.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE TMLICNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Indush-ial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPIACEMENTMETSOD&AMOUNT
\ . Non-Water Supply Well: �ft, Q ft. U/1e,-�,,OM
❑Mettitrig ❑Recovery ft. ft.
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(it applicable)
❑Aquifer Storage and Recovery LnSalinity Barrier FROM I TO MATERIAL EM:LACEMENTMETaOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑ erimental Technology ❑Subsidence Control ft. ft.
e0thermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FAOM TO DESCRIPTION color,hardness zdVrockAin sae,eat.
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks p /
I a t�
4.Date Well(s)Completed: S-�Well IN S ft. 3�v tt..
ft. it :
Sa.Well Location: Phone #�73::C�/— ff2F�/ ,^-^ '� >,—_•s- r-.-� --
Facility/Owner Name Facility MA(if applicable) ft• ft — 2022
-7 3 2—� (2 ► �rte i,.-e., bv,. PALai q �, ft. ft. c) cs
Physical Address,City,and Zip h ft {n;.+F .._ ,• .::' .r;,
21.REMARKS
Cocr_ty ParoelIdentification No.(PIN) BORES DEPTH
. l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: N LOOPS PER BORE ( ( ) DIA OF LOOPS ( )
(ifwed field,Doe lattloagissufficient) 22.Certification: SDR OF LOOPS (l )
� / N W
6.Is(are)the well(s): IGPermanent or ❑Temporary Sign of Ce ell Contactor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15ANCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
1f this is o repair,fill out(mown well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.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 OS
const-6 ti on -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: 3'9-0 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2©100)
24a. For All Wells: Original!form to Division of Water Resources (DWR), C
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwoter level is above casing,use"+"
f Borehole diameter: G (in.) Bit Off: 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 j
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
13a.Yield(gpm) Method of test: 00, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: 6I
h
ps-i rP-
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018