GW1-2022-09473_Well Construction - GW1_20221014

For Internal Use Only: i
1:Well Contractor Information:
K WATER ZONES i
Weil Contractor Name T FROM TO DESCRIPTION
��-lJre�14 ft. 1/0 It. ,Za�M
30
NC Well Contractor Certification Number ft ft a 6
P
15,OUTER CASING for multi-rased weus ORLII if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICElYESS MATERIAL,
ft.
Company Name / ,g 16.INIINTER CASING ORTUBING eothermaI closed-loo
2.Well Construction Permit#: '36/ �66 FROM TO DIAMETER MCI=SS n2ATERIAL
List all applicable well construction pennils rL e,EUC,County,State,Variance,eta) it Gs� m' �' v
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO MME M SLOT SIZE T87CItNESS MATERIAL
OAgriculturaI ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) tgResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial k6sidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL MaLACEMENTIMETHOD&AMOUNT
Non-Water Supply Well: ft' ?y IL cmCr Fourrel
❑Mcnitoring ❑Recovery ft ft.
Injection Well:
ft ft
❑Aquifer Rebharge []Groundwater Remediation
I9.5AND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Er"LACEMENTAm.MOD
❑Aquifer Test ❑Stormwater Drainage ft' ft.
❑Experimental Technology ❑Subsidence Control ft ft.
OGeothrzmal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION valor,hardness,soiVroe& 4 n size cte
❑Geothermal(Heating/CooIingRetnm) ❑Other(explain under Remarks) ® ft, 73 ft W
of
4.Date Well(s)Completcch. Q 7 ?2-WeuM# 3 ft 6r n L Le
5a.Well Location: Phone # ft. ft
$ �' ` /. ®�
Factlity/OvmerName ® FacilifyIIJfk(if applicable) ft ft
�4 ®res %e ft. ft 1 2Q2'
1 _
Physical Address,City,and Zip ft ft'
County Parcel Identification No.(PIN) I•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): Ffermanent or ❑Temporary Signature of 4crtifiedVell Contractor Date
By signing thisform,1hereby certify that the we/l(s)was(were)canstructed in accdrdcmce with
7.Is this a repair to an eidsting well: ❑Yes or Iwo - 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction,Standards and that a copy"
If this is a repair,fd1 out known well construction information d explain the nature of the ofthis record has been provided to the well owner.
iepairtmder121 remarks section or on the back ofthisform.
23.Site diagram or additional-we]]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�eeded. Indicate TOTAL NUMBER of wells (add See Over'in Remarlm Box).You may also attach additional pages if necessary.
drilled: 24.SUSMITEAL,INSTRUCTIONS
9.Total well depth below Iand surface: 30.) i.
(ft')
For multiple wells list all depths Ifdifferent(example-3@200'and 2Q100D Submit this GW-1 within 30 days of well completion per the following;';
i
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft)
Ifwater level is above casing,use"+ Tnfomuition Processing Unit,1617 MSC,Raleigh,NC 27699-16I7 '
'
A.Borehole diameter- (in,) Bit Off. 4�® a 24b,For In"i'ection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-163 6
12.Well construction method: AIR ROTARY
24c.For Water Supply and Opel-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depadihent of the county where installed
FOR WATER SUPPLY WELLS ONLY: - 24d.For Water Wells proda over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Rale'gfi,NC 27699-16I1
13a.Yield(gpm) d Method of test:
70%HTH I.: OZ DATE SITE VISITED:
13b.Disinfection type: Amount:
VISITED BY: � _