GW1-2022-10440_Well Construction - GW1_20221116

`�+COINS T RTJCTIIQN RE C��f C��-1) For Internal Use Only:
1.`Nell Contractor Infoor�ruition: y/�J
/'LLB T�'sSi../ t✓��//) 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
384? ft.-Imp ft. z 70 - zo 1 Z%a
NC Well Contractor Certification Number 7 Uft ' G 7� �D
15.0 TER CASING for multi-used wells ORLINER if a licahle
YADKIN WELL COMPANY,INC. FROM o clsxEss IRIALCompanyName 16.IN]NER CASING OR TUBING eothermal dosed-loo 2.Well Construction Permit#:N►CI6liz -t 't 3�i z �.+ t( FROM TO DUME7ER TffiCIOQEss r4A
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc) ft /► ! in. _ U A
3.Well Use(check well use): it ft. in.
17.SCREEN
Water Supply Well:
FROM TO DLAmrrim I SLUTsizE THicicrmss I MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irri atlon ❑Wells>100,000GPD FROM TO MATF•-rarer EMPI.ACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 19ft, '_
❑Monitoring ❑Recovery ft, ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EA LACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa r1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadcs) I
FROM ft. TO DESC MMONcolor,hardnm,:oil/mck e,grain sim etc.
3 G
- �l� t O ft.
ft.
4.Date Well Completed:�r� -ZZ Well ID# S
S-0
5a.Well Location: P j011@ # T +. ei°l--2l 4C S © ft. So l0t'/ 91
.v4 ft 72 Z ft a. �, �c-r ' CA
Facility/Owner Name,e y /Facility ID#(if applicable)�ble) ( ft. f
Physical Address.City,and TIP a Q{ ft ft
ii A k I Y\ 21.RE1vIARxs
County Parcel Identification No.(PIN) tn"✓ �
5b.Latitude and longitude in.degrees/minutes/seconds or decimal degrees: r{
(ifwell field,one lot/long is sufficient) 22.Certification-
6.IS(are)the well(s)-/<Permanent or ❑Temporary Signature of Certified Well Contractor Date:
By signing thisfarm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *a 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If ihis is a repair,fill out known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under d21 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMMAL INSTRUCTIONS
i
9.Total well depth below land surface: (ft.)
For multiple wells list all depths If diferent(example-3 c(�r 200'and2©100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: j/ (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level Is above casing,use"+" ! Inform onati Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter:_ (in.) Bit Off: U. 076 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well con AIR ROTARYstruction 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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
J Permit Program,1611 MSC,Ral%.NC 27699-1611 Y
13s.Yield(gpm) � Method of test: / A// j ci -114
70%HTH p Oz DATE SITE VISITED: �� ) ` 2 Mau
13b.Disinfection type: Amount: `i
VISITED BY: rsJ.1
Fnrm rw-7 orth Carolina Denartment of Environmental Oualitv-Division of Water Recourcea