GW1-2022-10302_Well Construction - GW1_20221114

N RECORD(GIN-1) For Internal Use Only:
11.Well Contractor Information: 1
Wai�k 14.WATER ZONES l
'.Jell Contractor Name FROM DIISCRIPTION TO
ft' /Jc It. .2, GPM►
74S'a A It 2W it 814PON �
NC Well Contractor Cmtificsfinn Numbe 15.OUTER CASING for multi-rased wells OR LINER if a licable 9L
YADKIN WELL COMPANY,INC. FROM I DIAMETER TarclavEss MATERIAL
v
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: / % L l LP FROM I TO I DIAM3nmR THICIOMS NtAT1 itIAL
List at/applicable well construction perm rs P.171C,County,State,Variance,etc) 1 P_ 0 ft / in. O R m p V c (�
3.Well Use(checkwell use): ft ft. V m f
17.SCREEN
Water Supply Welt:
FROM TO DIAMETER SLOT SIZE THICIINESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *rsidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERL4L EMPLACEMENT]% THOD&AMOUNT
Non-Water Supply Well: Oft' 1S % gOv«/ & eJ3
❑Monitoring ❑Recovery it ft.
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK sf a 'Iirahle)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPIACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft it:.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIlVG LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remado) FROM To I)PSC RWTION error,hudness,361/roex sae,etc
fr. 5-0 ft
4.Date Well(s)Completed: 0 2'el Well ID# �� SD ft. ;'%4t ft A.
Sa.Well Location: Phone # i, � �, —q3 L M- fL
it tt
Facility/OwnesName Facility MP(If applicable) fr' R
fr. ft IN
Physical Address,City,and Zip it ft
St�Q0 21,REMARKS
i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one 1aUloagis sufficient) 22.Certification:
3� C7 .�f 3 9 N T! 3Q 1,4J/ W 10( 2412
Signata of C
6.Is(are)the well(s): Permanent or ❑Temporary ' ed Well Contractor. Date
By signing thisform,I hereby cent that the well was(were)conshucted in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction SYandarris and that a copy
7.Is this a repair to an existing well: oYes or *0
If this is a repair,fill out)mown well construction bformalion and explain the nature of the of this record has been provided to the;well owner.
repair under 121 remarks section or on the back of thisform.
23.Site diagram or additional yell 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 ryeeded. Indicate TOTAL NUMBER of wells (add See Over'inRemarics Box).You may also attach additional pages if necessary,
drilled: / ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z (ft)
For multiple wells list all depths Ifdifferent(example-3(a)200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
I
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f water level is above rasing,use"+" Information Processing Unit 1617�MSC,Raleigh,NC 27699-1617
Bit off: •VOY 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�) Program,1636 MSC,Raleigh,NC27699-1636
AIR ROTARY
12,Well construction method: 24c.For Water Supply and Opexi-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
13a.Yield(gpm) `� Method of test: ��� T(�1
136.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: �C 17�a 2' �
ITED BY:
Form GW-1 =Carolina Department ofEnvironrnental Quality-Division of Water Resources Revised 6-6-2018