GW1-2022-10307_Well Construction - GW1_20221114

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WELL CONS RU -1 I tCORD(1a 'W-i1) For Internal Use Only:
1.Well Contractor Information:
_) r t/1 I " I�' s 1f..i?'► 14.WATER ZONES
Well Contracto ame FROM: TO DESCRIPTION
ee
a 7,2=A NpV 1 A 331 a •• � �
NC Well Contractor Certification Numbs
lnrOt'4344 022 15.OUTER CASING-for Multi-rased webs ORLDVER d a livable
YADKIN WELL COMPANY,INC. Q t Pr;� FROM TO DrAt�TER THICKNEss MATERLIL
ft. ft. in.
Company Name / 16.INNER CASING OR TUBING eothermal rlosed-loop) 0
2.Well Construction Permit#: f' 7 �- FROM I TO DIAMETER THICKMS I NIATEHLIL
List all applicable well construction panm s(1.e.UIC,Coin,State,Variance,etc) 4 1 IX ft ����in. 154DK-al I P G
3.Well Use(checkwell use): ft ft' 1II'
Water Supply Welk17'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 7
❑Agricultural ❑Municipal/Publio ft. ft. in.
❑Geothermal(Heating/Cooling Supply) L[tesidential Water Supply(single) ft ft,
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrl atiOn ❑Wells>100,000.GPD FROM TO MATERIAL EMPLACEMEWTMETHOD&AMOUNT
Non-Water Supply Well: ft. 3' ft. G*} iur
eqf
❑Monitoring ❑Recovery 3 it. a> ft. Ai Sfatfr v^
Injection Well: N•
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bailer FROM TO MATERIAL En7PIACEMENTIY=01)
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessarylW
❑Geothermal(Heating/CooUng Rchmm) ❑Other(explain under#21 Rematics) FROM TO DESCRIFTTON color,hardness,saillrotktypr,krmin sve ate
fl. Jos o
4.Date Wel](s)Completed:l0. 5-��-WeII ID#�`IA/ 7 ft. Io°rt I)prk ;40
5a.Well Location: Phone# SS2$-��d-j('Y8 ft 1120 fL 1-7 pp r
r ft ft �
F ty/OwaerNeme FacilityID#�ifapplicable) ft ft
/ n� ,
(.�Ut :P �/6Rlef bun. wal:reAS'Nr'l/e,- ovr'�#L � -�Q0
Physical AdrhrCe,c i,and zip J© - wt dl r.'!kd A q a ' (�
S / 21.REAfARKS 1 D aw!
county `1 Parcel Idenfifrcation No.(FIN) 04�+vt,7Y/- ✓ s v c3 a-li
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees: e
(ifwall field,one latMngis sufficient): 22. ea' r ��,,,pp a oc c 4
�o�d ,.
IYV �
6.Is(are)the well(s): [Permanent or ❑Temporary Si re of CKfied Well Contractor, Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eiusting well: ❑Yes or *0 15A NCAC 02C.0100 or ISA NCAC 02C.D200 Well Construction,Standards and that a ropy t
If this is a repair,ftll out!mown well constmWon informailan and explain the nature of the of this record har been provided to the well owner.
repair wader J21 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 Oval'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths/fdifferenf(emmple-3@200'and 2@1001
0 24a. For All wrils: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) hrfbrmation Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use
o
( ) Bit Off: 5, 24b.For Injection Wells: Copy Ito DWR,Underground Injection Control(TUC)
11.Borehole diameter:
Program,1636 MSC,Raleigh,NC 27699-I636 1
AIR ROTARY (�M
12.Well construction method: 24c.For Water Supply and Opeu-Loop Geothermal Return Wells:Copy to the ^
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed yI
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells yroducin g over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 �� Method of test: Cl P
a q DATE SITE VISITED:
13b.Disinfection type; 70/c HTH Amount: OZ �
PtirP i -- - - VISITED BY: y I