GW1-2021-07082_Well Construction - GW1_20210915

IVVE kRUCTION RECORD (GW-11) For Internal Use Only:
I.Weil C tractor Information:
SID14.WATER ZONES
Well Contractor Name FROM I TO J_DESCRIPTION
3
//0 ft. %L I
20-IM
036_4 Sr ft. I I I q ft.
NC Well Contractor Certification Number 15.OUTER,CM�ruglh— d,,well,'OR LINER 1Ppqli1_ P
DIAMETER
YADKJN WELL COMPANY,INC. FROM TE TH15g?TES MATERIAL
Company Name h" 16.INNER CASING OR ING(aeothermal closed-loop)
2.Well Construction Permit M tk)S M 0/1 T 2' FROM TO DIAMETER THICICNE,SS I MATERIAL
List all applicable well construction permits rie.V7C,Coun6,Slate,Variance,etc.} I
+ I f ft I. It t iL
3.Well Use(check well use): —ft. I ".] in.
WaterSupply Welk 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICI4YESS MATERIAL
DAgricultural OMunicipal/Public ft. ft,
OGeothermal(Heating/Cooling Supply) *6,id.,tial Water Supply(single) �ft- ft in
01ndustrial/Commercial DResidential Water Supply(shared) 19.GROUT
oh-rigation oWells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: ft. ft. :4 .11/2,
OMonitoring ORecovery Y_
Injection Well: J A e
V
OAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if apOlicable)
CAquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control ft
oGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
oGeothermal(He!!tg/CoolingRetum) 00ther(explain under#21 Remarks) I FROM TO - DESCRIMON(color,hardness,soll1rock type,gnin size,etc.)
ft .'5F ft.
f4m
4.Date Well(s)Completed: WPUID# 1/0
A* so - /a,
5a.Well Location: Phone # SX-34-7- 'YQ 304- —ft 699-^A
&a S e t O—i 4—S - 3 OX f- 3 6 Vt ra�At
FacilitylOAcir Name Facility ID#(if applicable) ft ft, n F7
521 -7 t6Zddl Al Va A k ton ut' ft ft. 4 N1*,_1�1_..''"a V
Physical Address,City,and Zip ft. ft
21.REAMRKS 1
County Parcel Identification No.(PIN) --_' n-P J
�
t! I,
07 R,'*j 0--RO 5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification.
N
6.Is(are)the well(s): dermanent or OTemporary Signature of Certified Well Contractor Date
By signing thisforni,I hereby certify that the well(s)was(were)constructed in occor&mce with
7.Is this a repair to an existing well: OYes or 19/0 ISANCACO2C.0100oriSANC4CG2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner•
repair under#21 remarks section or on the back of this form. 23.Site diagram or addition'al 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 I I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled_ 24.SUBMITTAL.INSTRUCTIONS
9.Total well depth below land surface: -(ft
For multiple wells list all depths 1fdifferent(example-3@200'and 2@1001 Submit this GWA within 30 days ofwell completion per the following:
0/0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)If water level is above casing,,use 11, Information Processing Unit,'1617 WC,Raleigh,NC 27699-1617
11.Borehole diameter:
I C' (i..) Bit Off: Cr 06j 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,
NC 27699-1636
12.Well construction method: AIR ROTARY on For Water Supply and I 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 D CC-P A
13a.Yield(gpm) Method of test: Perm; Program,1611 MSC;Raleigh,NC 27699-1611
Z4 C>
13b.Disinfection type: 70%HTH Amount- a? Oz DATE SITE VISITEn:
114.Rn