GW1-2022-08922_Well Construction - GW1_20220912

LL 6:QNSTR UCTIQN RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informntion:
/a �7{jQL✓ ��j W Y) K WATER ZONES I
OM DESCRIPTION
Well Contractor Name FR TO
ft. ft.
3 D 3 l A ft. ft. I k
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM To IANatTER', TEICLINESS _ MATERIAL
Company Name 16.INNER CASING OR TUBING 'eothermal closed400 )
2.Weu Construction Permit#: LSD In/E L N 1- 414/n w u FROM TO DIAMETER Tfficlavrss MATERIAL
List all applicable well construction permits(ce.(IBC,County,State,Marionce,etc) °1 ft -7 / it
g �n SG qO .
3.Well Use(cbeckwell use): d ft' / ft' in. 7
Water Supply Well: �-�// i 17.SCREEN
PPY JCIyp \ FROM TO DIAMETER SLAT SIZE TIUCICNrSS MATERLIL
❑Agricultural CIunicipal/Public ft. in. $�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. F?v�
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft' '7 ft' 4'�H �v S?
❑Monitoring ����. ��3�e� it. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge P S dwaterRemediation t 19.SAND/GRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑5�' 'i�L ter FROM To RLAL iPLACEMENT AMEOD
❑Aquifer Test If Dfl t 4`ter g09prawater Drainage ft
�,RIC3J
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hiHnus,aoiVrock .du sbi,etc
S 1 0 ft it. Scot,/
4.Date Wells)Completed: 6` Lt(- Lt well ID#Al 4 ft' U ft. S4.2'ji c, Zmt4lka
5a.WellLocation: Phone # 60 ft 40 ft' 6,,
Ca r c�u� Scj 1 ft. ft
�u
Facility/Owner Name Facility MA(if applicable) ft' ft
(,AL ft. ft
Physical Addms,City,and Zip ft ft
At u rt C 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
cp
6.Is(Rre)the well(s): 91 ermanent or ❑Temporary Signature of Certified Well Contractor Date
�� By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
9
7.Is this a repair to an existing well: ❑Yes or 4140 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known wall construction information and erplain the nature of the of this record has been provided to the well owner.
-repair under#2l remarks section or on the back offhisforin.
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
construction,only 1 GW%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: /00 epZ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdiierent(erample-3@200'andl©100D
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
lfwaier level is above casing,use"+" 2/
Bit Off: /le 24b•For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Oplen-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
) r Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gpm
13a.Yield Method oftest:/t/✓ //Y
70%HTH OZ DATE SITE VISITED: 2c
13b.Disinfection type: Amount: f
VISITED BY:
r A nn1 a