GW1-2022-10320_Well Construction - GW1_20221114

�WE sCONS TRUCTION RECORD QW-1) For Internal Use Only:
I.Well Contractor Informatioo: �`'
R °V E 14.1VATER ZONES
Well ContractorNNy e NOV 1 4 2022 %ROMCFt TO ft. pESCItIPTION
NC Well Contractor Certification Number Ifl+`OfiS. O;��R''"' Una rift. ®pj®' ft
rjy"G urOG IS.OUTER CASING for multi-cased yells LIIgERk if a livable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICECNEss MATERIAL
p� ft. ft. in.
Company Name �,� a�� r" �" a 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#. u � FROM TO DIANILTER THICIQQFSS BTATMUAL
List all oppllcable well construction pet7nils(!,e f11C,County,Slate Variance,etc.) ft ft !� �5-iu- ��
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TEICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) eesidential Water Supply(single) ft. ft.
Oludustrial/Commercial ❑Residential Water Supply(shared) IB.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MnTHOD&AMOIINT
Non-Water Supply Well: it. ft. C'.Gl c may.iepe
❑Monitoring ❑Recovery S it ��' ft. p,4_- �
Injection Well: °�
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if ap plicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM:P1ACCMZNTM=- OD
OAquifer Test ❑Stormwater Drainage ft. ft.
[]Experimental Technology ❑Subsidence Control fL ft.
❑Geothcrnal(Closed Loop) ❑Tracer 20.DRILLINGLOG attarhadditional sheets ifaecessa
❑Geothermal(Heating/Cooling Bebmm) ❑Other(explain under421 Remarks) FROM To DFS(St=ON mmr;hm-dness,soilfmcktypr,gndn sirs,em.
® ft. 7,0' ft. 50,L /
4.Date Well(s)Completed: — Well ID# AA P' 77Co ft' 176 ft f�O osc` GL�@sz ?'y' me
5a.Well Location: P h o n e #_T3C—cl-0 Q fL 2,eft
Y V116QQ e\ ft ft
Facility/ erName Facility]D#[rfapplieable) ft ft
�tq-2 T'4"�eV4'� R.i &duo 'ems ft. it
Physical
Address,City.and ' ft it.
DOVA 21.REAL431 CR
County Siii Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): 0Ipermanent or ❑Temporary SI!016e of CirtiftFd WA ConiSartar Date
By signing thisfarnm,I hereby certj)�that the wall(s)was(were)constructed in accordance with
7.D this a repair to an existing well: ❑Yes or MN-01 15A NCAC 02C.0100 or I5A NCRC 01C.0100 Buell Construction SYandards and that a copy
If fhfs is a repair,fdl out IPmown well construction information and explain the nature of the ofthis retard has been provided to the well owner.
repair under ill remarks section or on the back of this form. .
23.5ite diagram or additicnalwell 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.SUBUTITAL INSTRUCTIONS
9.Total well depth below land surface: � (fL) Submit this GW-1 within 30 da s of well completion per the followin
For multiple wells list all depths If different(example-3(rr]200'and IQ100) y P P g
10. 24a. For All Wells: Original form to Division of Water Resources WR),
Static water level below top of casing: (it) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ifwater level/s above casing,uself "+"
II.Borehole diameter- (in.) 131t Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) G
Program,1636 MSC,Raleigh,NC 27699-1636 C S
AIR ROTARY '
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc) county environmental health departrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: aa 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: ' °d�;C P.r _ Permit Program,1611 MSC,Raleigh,NC 27699-1611 m
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: �� ---_ ��✓ ° �
Pri re
VISITED BY: ®�