GW1-2022-09483_Well Construction - GW1_20221014

_k u,L CONS TITiUCllT ON RECORD fIGW-11 For Internal Use Only:
1.AWell Contractor Information:
JO(i� 1V,Ukk,5
14.WATERZ.ONES
Well Contmatorflaxne r FROnf I TO I DFSCRVTION - �j a
sut`5C Ar-C,
NC Well Contactor CeetiSeationxumber
IS.OUTER CASING formuld-rased s ORLUVER Ille Ecuble e
YADKIN WELL COMPANY,INC. FROM To 1 InAbrir IM 1 TRICKxMs MATSNAL-
ft. ft in.
CompanyName py 16.n%NM CASING OR TUBING athermai rase&loo
2.Well Construction Permit#:�2 sA 7(�r�l(/ FROM TO 3) MTE tI TmCIeM99 MANMAL
List all appllmble well construction permits(Aa EUC.County,State,Yarinnce,eta) VC IL i R It ��l.s' 1- ,j�N � VC.
3.Well Use(ebeckwell use): ft I k' in.
Water Supply Well: 17.SCREEN
FROni 70 DIM1LfER I SLOT SIZE I Tmm[NFSs I MATERIAL
DAgricuktural DMunicipal/Public R. R. in.
OGeothetmal(Heating/Cooling Supply) 906sidential Water Supply(single) R ft is
Dindustial/Commerciak - DResidential Water Supply(shared) 18.GROUT
01nigation Dwells>100,000 GPD FROM I TO I MATEIUAL Eh2LACEV=TMETB0D&.ANDMIT
Non-Water Supply Well: D fit. R eA-Ain. gotoreqf
OMonitoring ORecovery 3 ft, as' tt. .13fI-Slfat oa,
injection well: -
[Aquifer Recharge OGroundwater Remediatioa ft R.
r Storage Recovery OSalmi Barber V.SANDIGRAVBIIPACRfdn Brable
DAtluibe rag overt' ty FROM TO 'MATEatALI MdRACEMiNT METH01)
OAquifer Test OStmmwater Drainage R I ft -.
DEquimental Technology OSubsidence Control ft. I it. W
OGeotheermal(Closed Loop) OTmcer 20.DRML]NGLOG2dach additional sheets if necessary)
FROM TO ➢FSCRIMONrelax hnda¢e,a°iV
mrk sve,eR
❑Geothermal(Heating/CeolinpgRefma) DOther(explainAunder#21 Remedcs) R
4.Dat:Well(s)Completed*1 —09-:1 WelliD# /7�D�74 fl- eAW11-
t f
5a.WellLomiion: Phone ft RL -r + oc tp
Mi`� [Al. Ce � !ma eoars ae .FecilitY/Oxm¢Name FadzyID#(ifm icable) ft R
�al,G li�rl�®6. 33G-Y2?-z7'd H. ft _
Physical A,dd(ress,C/ity.and ZiP ,/ R fe - OCT I
�Yt1R.p37 6 r-C/t 2L rzmvrAnrrs
County Parcel TdentificsdonN (PIN
5b.Latitude and longitudeW degrees/minutes/seconds or decimal degrees: _
(ifwcn field,one lat/longis sufficient) 22.Certification:
3 6 33• A204Z N 8r!Z Z W
6.Is(sre)the well(s): kermanent or OTemporary Silp9lireofC 'ed Well Contractor Date
Eysilinbtgthlsfarm,I hereby cerlifythat the well(s)was(were)constructed inaceordnmmwiM
7.Is this a repair to an existing well: DYes or )v0 15ANCAC 02C.0100 or 15AVCAC 02C.0200 Wdl Construction Standards and(hat a copy
Ifthis Isa repolrfJ/out known well conthucfion lnfarmotlon andexplaht the nahae ofthe offhismcardhasbewpmvadtothe"llowuer.
repairveder$21 renia6asedton or on the back ofthfsfarm.
23.Site diagram,o;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 wall construction info
construction,only I GW-1 is needed Indicate TOTALNUMBER ofwells (add See Over'its Remarks Box).You may also attach additional pages if necessary.
�cdl ! 24.SUBlt4T TAT INSTRUCTIONS
9.Total well depth below land surface: y�� —(ft-) p per er Submit this GW-1 within 30 days of well completion the following:
Fiermultiple wells list all depths iire7fermI(emmple-3@200'mrd2@1000 g'
JS r 242. For All Wells: Original fora to Division of Water Resources (DWR),
Ifxvler love!Is above rosin
ID.Static water leosin%,use below top of rasing: a (ft) Infomtation Processing Unit,.1617 MSC,Raleigh,NC 27699-1617
"+"
11.Borehole diameter:�C ,(in.) Bit Off:.14�6 90 74b.For lniection Wells: Copy to DWR,'Undergmund injection,Control(IUQ
Program,1636 MSC,Releigb,NC 27699-1636
't�5
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.e,M.rotary,cable,dueetpusb,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Well producin¢over 100.000 GPD: Copy to DWR,CCPCUA
m,:1611 -1611 MSC,Raleiglx NC 27699
13a.Yield(giro) Method of test: a d v Femut Pro gra Z C
136.Disinfection type: 70%HTH Amount 1�• s OZ DATE SITE VISITED: _C2 --I
P T'i r.p. i
VISITED BY: Me