GW1-2022-10437_Well Construction - GW1_20221116

WELL CONS TRITCTION RECORD(GNV-D For Internal Use Only:
! 1.`Vl'81 Contractor Information: _
a �v 1),
)�� 14.WATER ZONES
- �.n} s ° PROT4 TO DESCRIPTION �,/�
Well Contractor Name II®pft f I ft �`��} (-4t K C Wa3`'
15 11,1 5 ft. ft. (` „2
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells OR LINER if a Gcable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCKNESs MATERIAL
ft. ft, in.
Company Name 16.INNER CASING OR TUBING eethermal closed-too )
2.Well Construction Permit#: FROM To DIAMETER 7MCICVEss MATERIAL.
List all applicable Hell construction permits(i,e.UIC,County,Slate,Variance,etc) 1 ft 1,50 ft � in. '2 2
3.Well Use(check well use): ` fL ft. in.
17,SCREEN
Water Supply Well: FROM I To I DIAMETER I SLOT SIZE I THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft, in
•
❑Gectllermal(Heating/Cool ing Supply) tesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft. ft. .kok 1 e�
❑Monitoring ❑Recovery iL n fti
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EnffIACEML+NTXMoD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) FROM To DESCRIPTION color,hardness,salhvck a in sae ere
^ n � p 0 � fL '!
4.Date Well(s)Completed: V�b - Well ID#BALM l- ft 1 ft tit t R7C
KS
5a.Well Location: Phone # d�cel - �"�� fL ( � rd`CK�Lh�
dKytA
Facility/Owner Name Facility ID#(if applicable) ft• ft
A5/K �6`�Lw � GN
Physical Address, ,and ZipV fL ft.
21.REMARKS L
County /1 Patcel Identification No.(PII 1) ,. „
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
$ �
3 7c � f N l
� 3 � �. .. 3� � � IQ 10
6.Is(are)the well(s): ermanent or ❑Temporary SighlEre of CeMfiea Well Contractor Date
By signing thisfarm,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *0 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information ohdexplain the nature of the of this record has been provided to the well owner. _
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details: 4
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 t
construction,only 1 OW-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:_ , (ft) Submit this GW-1 within 30 days of well completion per the following: p
For multiple wells list all depths if different(=ample-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 5?A (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
]fwoter level is above casing,use"+" II
Bit Off- 0'i 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) 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
(i.e.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
13a.Yield(gpm) 0 Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
��l/
70%HTH , OZ DATE SITE VISITED: y
13b.Disinfection type: Amount: p
VISITED BY:
Pri ca-