GW1-2022-10299_Well Construction - GW1_20221114

RECORD d;GW_1y For Internal Use Only: -
1.Well Contractor Information: -
.)CtN Wa4-IC14 14.WATER ZONES - M
FROM TO DEsCrUSTION
Well Contractor Name ft. ft.
.0 Li S714 ft. it
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a ticable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCrINEss MATERIAL.
ft. ft, M.
Company Name y �}�yyy 16.INNER CASIIdG OR TUBING Ipeothermal closed-loo
3 3`� 9b FROM TO DIAMETE!fr_7�0
AIATrMn
2.Well Constivction Permit#: adate+ � a Llst all oppllcab/e well rnnstruction permits(i.e.EUC,County,State,Variance,etc.) + ft SA4 it ft ft,
3.Well Use(check well use): -
37.SCREEN _
Water Supply Well: FROM TO DIAMETP;a sLOT srzE TEaCKNESS MATELUAL
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
DIndustrial/Commercial []Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100.000 GPD FROM TO nfAnMkl, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. ft. Hd Jr.P FG.rea1 3
DMonitoring DRecovery 3 ft d K• Gar+��E �u
Injection Well:
[]Aquifer Recharge ❑Groundwater Remediation
Q 19.SAND/GRAVEL PACK if a Mcable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MAT]nUAL EnffLncEMExzIVIETaoD I
DAquifer Test ❑Stormwater Drainage ft' it. -
c,
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addHoiW sheets if necessary
FROM TO uzz LiiIPTION color,hardness,soiVraek 4 ain size,cte
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) b ft. LI, it. 5011
car
(s)Completed: Well/C toI2.2
4.Date We �.,2q�' e.f�l ft >r3�2 Gra��n� t-
ll Com :
_ fL ft
So.WellLocatiory1�ys7'-t,F5 12 # 9110 ft ft -
14 V it. it
Factlity/OwnesName Facility ID#(if applicable) - `� 'I I r 0
i c � 5
ft. it -
Physical Address,City,and Zip T ft ft. - N n V I A 2 0 L
PhY 21.REMARKS _
County Parcel Identification No.CMD erMtO
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwcU field,one lat/longis sufficient) 22.Certification'
N g� 3L. ✓'Zd W
/ Sig ertified Well Contractor Date
6.Is(are)the well(s): t3Permanent or ❑Temporary nre of
By signing thisform,I hereby certi)5 that the wet/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or L°fNo 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to.'he 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
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: 13, (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths jdffferent(examp7e-3@200'and 2©100D
24a. For All Wells: Original i.'orm to Division of Water Resources (DWR),
10.Static water level below top of casing: JDD (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
Bit Off: 6
'00 24b.For Iniection Wells: Ccpy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and OlEen-Loop Geothermal Return Welts:Copy to the
(i,e,auger,rotary,cable,direct push,etc.) county environmental health d:pautrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: l r �
70% HTH Amount: SV OZ DATE SITE VISITED:
13b.Disinfection type:
VISITED BY:
wn tlr CarelinaDeoartment of Environmental Ouality-Division of Water Resources R^"'^d F-( rrt