GW1-2022-09542_Well Construction - GW1_20221014

VWER r;''ONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
ff/ )twi 1 14.WATER ZONES i
Well Contractor Name FROM TO I DESCRIPTION �^
3 O 3 6 A 3 SD ft 3si- ft-
ft, it
NCWell Contractor CertificationNumbcr 15,OUTER CASING for uld-casediyeils)ORLINER(ifzp licahle
YADKIN WELL COMPANY,INC. FROM D Tffi MATERIAL
ft in.
Company Name e
A/ 16.INNER CASING OR TUBING eothermal closed-loon)
Z.Well Construction Permit#: O , FROM Ta DIANM-"= TMClCCOS NIATERIAL
List all applicable well construction permits(aa.WC,County,State,Parlance,etc) .� � ft. L/S' it ' e!tf in. SAC 2 1 1 P
3.Well Use(checkwell use): R f' in.
W ter Supply Well: 17.SCREEN
FROAS TO IA DMETER SLOTSIZE THICJC�IESS MATERIAL
Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, it.
❑Industrial/Commercial ❑Residential Wafer Supply(shared) 1B.GROUT
[]Irrigation []Wells>1007000 GPD FROM I TO nuTE14AL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: ". ft. al; ,
❑Monitoring ❑Recovery it ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation -r
❑Aquifer Storage and Recovery ❑Salinity Bairier F9ROhSA2riID/GRA PACKCda ble) LACEMENTMETHOD ID
❑Aquifer Test ❑Stormwater Drainage
❑Sxpernnental Technology ❑Subsidence Control ft it
.176eothermal(ClosedLOop) ❑Tracer Z0.DRILLINGLOG attach additional sheets ifnermsary)
l7Gebthermel(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM To DESCIiIPTTON color,hardness,mivroek S tin:oz em
0 ft. f% ft. ms®
4,Date Wells)Completeri: � Z weuID# /8ft. yo® it k/a'
5a.WellLocation: Phone # �y..p . �"6r'o�4ft' ®�
Eve, H684- ( ft. ft
Facility/OwnerNama BadlityID#(ifapplicable) ft. ft. -:•e ,g-
ft. ft v.�. I `d• 1.3,
Physical Address,City.an Zrp ft ft
2022
21.REAiAPM
QeaA��
County Parcel Identification No.(PIR)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcllfield,onelat/loongis sufficient) 22.Certification:
c�l�- -6 .� 11 N �5 L.Y, S f . -7 W F-
6.Is(are)the well(s): 411,anent or ❑Temporary Signature of CeitifiedWell Contractor, Date
Bysigning thisform,1hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 940 15ANCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
,phis is a repair,fill out knawn well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under f2l remarkr section or on the back of this form.
23.Site diagram or additionalwelI details:
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
construction,only 1 G 1 is needed. Indicate TOTAL NUNMER of wells (add See Over'in Remadm Box).You may also attach additional pages ifnecessary,
drilled: g 24.SUBNEa-.E L INSTRUCTIONS
9.Total well depth below land surfacer —(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ift ffetent(example-3 c@200'and 2@1001 .
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: �� (ft) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use"-a'
11.Borehole diameter (in) Bit Off' 6' 117 74b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger.rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) �� Method of test: fI'G a( Jai�'
c o ITE VISITED:
13b.Disinfection type: 7D/ HTH Amount: �� OZ
Pri re--- - -%-- D BY: 095