GW1-2022-10306_Well Construction - GW1_20221114

CQNS 1TR� CTIQ R 1CQRD dGWV 21 For Internal Use Only: I ,.
1.Will Contrac``too-r__Informntion: E I"
y WQr t✓13 14.WATER ZONE3
Well Contactor Name FROM TO DESCRIPTION
?70� 1M
f S S GPM
NC Well Contractor Certification Number
15.OUTER CASING for uiniti-�ar.'d*ells)ORLINER d e licahle rj
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TffiCKNEss MATERIAL
ft. ft. j in. �
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.well Construction Permit#: V l FROM To I DIAMETER I THICKNESS I MATERrAL
List all applicable well construction permits(ie.WC.County,State,Variance,etaJ m 10f ft `1fy in. S Da" �f Jc
3.Well Use(ebeckwell use): ft. `n• I"
Water Supply Well: rROM�TO DIAMETER SLOT SIZE THICKNESS MATERtAL
❑Agricultural - ❑Mlmicipal/Public ft. ft. W.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft' 73 ft. 4 (r PIC4 POvfetel
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Ua licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier mom To MATERIAL EMPIACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
t T ❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) I'HoM ft-
TO � DESCRUTlox polar,hardness 6ovrock n:;u ace
AA b / l
4.Date Well(s)Completed: I I Z �1 well ID#�/7�"��� Ob 5lra2 ft• 6nan.4
`:,-Za.WellLocation: L0-;,gkb6n Phone # ff,,>3-g0S 3�W
it-�Jil ft it
,; It
ty/Owner Name Facility M#(if applicable) ft ft.
ft.
Physical Address,City,and zip
ft it `
S ri �J � atUgL 21.REMARSS
County Parcel Identification No.(PIN) rt?te.3@"U►tdl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
w w l l Z 1 22
6.Is(are)'the well(s): pwermanent or ❑Temporary Sign re of Cktified Well Contractor, Date
By signing thisform,I hereby certify that the we/l(s)was(were)constructed M accordance with
7.Is this a repair to an e3dsting well: ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction.Standards and that a copy
if is a repair,fill out known well construction information d explain the nature of the of this record has been provided to the well owner.
repair under f21 remarla 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 GAT 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: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths 1f different(example-3 c©200'and2©100)
3 d (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit 1611 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" 1.
Bit Off: L•d1S 7Ab.For Injection Wells: Copy1to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•) Program41636 MSC,Raleigh,NC 27699-1636 T 4„
AIR ROTARY �-
12.Well construction method: 24c.For Water Supply and Ope`-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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: 70%HTH Amount: { OZ DATE SITE VISITED:_!�. �_� I .2
VISITED BY:
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