GW1-2022-10313_Well Construction - GW1_20221114

/�L?�ei'MS T1�'�J�;1T1�CD1�i� ,�CO D (eG�FT-1a For Internal Use Only:
I.Well Contractor dnfornntiow
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14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3® ft' /3 (WP^
NC Well Contractor Codification Number ft• a ft t
15.OUTER CASING for multi-rased wells ORLINF.R rf a licable
YADKIN WELL COMPANY,INC. FROM To/ DIAMETER TfficAnflvE^ss MATERLw
Company Name P-� .73G. `Ise;b.- :3f-. Q�T +- ft. in. s�R^O v
16.INNER CASING OR TUBING eothermal dosed-loon)
2.Well Construction Permit#: � `t''l FROM To DIAMETER THICKNESS MATERIAL r
List all applicable well construction permits(ix-MC,County,Slate,Variance,etc.) ft it in.
3.Well Use(check well use): ft ft. in. Cz
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fr. in.
❑Geothermal(Heating/CooIing Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation Dwells>100,000 GPD FROM I TO MATERIAL / EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 2 ft, p f jAe{eCN� �N► t/w dLGL
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft. ti:
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAYEL PACK Cif a licable)
❑Aquifer Storage and Recovery,„ 115alinityBarrier FROM TO MATERIAL rMPTACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geoth=al(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retina) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soSuroek a sac ccc
O ft ft
4.Date Well(s)Completed' �OJ� 0- WellID#. /'-'1'&lam® 2 t® f' (.O ft
5a.Well Location: Phone #J!(,—tZ-/'J Y 0 ft G fL
ft ft '
Facility/OwnerName Facility M#Cif applicable) R• fL
ft. it
ft ft Nev
i [
Physical Address,City.and Zip M� b ,
y 21.REMARKS
R I rh`u^fiT z!s
ks d nq
County Parcel Bentification No.UUN) C%A+QI30G
5b.Latitude and longitude in clegrees/minutes/seconds or decimal degrsees:
(ifwell field,one laUlongis sufficient) 2.Certifica'on:
,� CN
6.Is(are)the well(s): f�Permanent or ❑Temporary Si e o ertified Well Contractor Date
By signing thisform,1hereby certify that the well(s)was(were)constructed in accordance with
r 7.Is this a repair to au existing weII: ❑Yes or Dill 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ythis is a repair,fi11 out brown well construction information anderplain the nature of the ofthis record has been provided to the well owner.
repair under 121 remarks section or on the back afthis form.
23.Site diagram or additionalwelI 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.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: (D) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(mrampie-3Qa 200'ann1d 2Q100)
S V ft 24a. For All Wells: Original form to Division of Water Resources (DWR), �e�
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-16I7
]fwater 1eve1IS above casing,use"+" CA
ft.Borehole diameter- (in.) Bit Off: 9 TO 3 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NC 27699-1636
12.Well construction method: AIR ROTARY 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
13s.Yield(gpm) 1� Method oftest: YT�� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:-
Pr7 r VISITED BY: