GW1-2021-00171_Well Construction - GW1_20211109

IT;tbNSTRUCTIQN RECORD (GH-1) For Internal Use Only:
1.Well Contractor Informntion:
4� �tJ•` v 14.WATER ZONES
FRO
Well Contractor Name 1MI TO DESTION
.� S 7 a-A �
ft. ft f /�
NC Well Contractor Certification Number 15.OUTER CASWG formulti-used wells ORL= if a Ucable �Y
YADKlN WELL COMPANY,INC. FROM To DIAMETER TfficsarEss MATERIAL
r � � 3� ft ft. in.
Company Name f -P� 3�g�V" T 16.INNER CASING OR TUBING 'eothermal closed-loon)
2.Well Construction Permit#: ®1 T t FROM To DIAMZTER THICKNESS MATERIAL
Llsi all applicable well construction permits(i.e.U1C,County,State,Variance,eir-) ft77 it "! /fn'
3.Well Use(checkwell use): R' ft. m.
Water Supply Well: 17.SCREEN
pP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft in. �f
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. ft. in.
.o r
❑IndustrialtCommeacial ❑Residential Water Supply(shared) Is.GROUT `y
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMINT METHOD&AMOUNT 5
Pion-Water Supply Well: d ft ft Pn,� �• 08)rty/
❑Monitoring ❑Recovery ft �
ems! Len
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAPID/GRAVEL PACK rf a licable)
❑Aquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL EMFLACEMENTIVMMOD
❑Aquifer Test ❑StolmwaterDrainage ft. R•
❑Experimental Technology ❑Subsidence Control - ft ft.
❑Geothemnal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Rol un) ❑Other(explain under421 wmarks) FROM To DEseR�TtoN color,b,raa� :ovrerx �n3t�ice
4.Date Well(s)Completed: l/ 3-a( WeII ID#E f 1 �` �6/ R 0 R'fL ft
q�cf '� �� /apiP i•
5a.Well Location- Phone-# 'Txedo. �33�C
^- ft ft
Farflity/Own4Name Facft][D#(if applicable) ft ft tom, l _ 'r itt'
Physical Address,r® t/City,and Zip ft f� e.J
Cormty Parcel Identification.No.ON)
i7.1�,....itll iWl'1 I'"t1 V,�r,.JJli4•,r l%i it I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lones suffrcimi) 22.Certification:
7% (, i�, a//�.s N �/"Ott. 3�1 W �Gc/
6.Is(are)the well(s): f aJPermanent or ❑Temporary Si re al Cero9d Well Contractor Date
By signing thisform 1 hereby cerhfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or f 111 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fdl out known well construction informatlon and explain the nature of the of this retard has been provided to the well owner.
repair under#21 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 n�eded. Indicate TOTAL NUMBER of wells (add'See Over'in Remado Box).You may also attach additional pages if necessary.
drilled: f1 a 24.S'UBNIITTAL INSTRUCTIONS
9.Total well depth below land surfacer (ft' Submit this GWA within 30 days of well completion per the following:
For multiple wells list all depths if eWerent(example-3(a)200'and 2 1000 )
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+"
Bit Off: e� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in) program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
72.Well construction method: 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 WELLS ONLY, 24d.For Water Wells product I g over 100,000 GPD:Copy to DWR,CCPCUA !
13 a.Yi el d(gpm) , Permit Program,1611 MSC,Raleigh,NC 27699-1611
Ky Method of test:
13b.Disinfection type:
70%HTH Amount: OZ DATE SITE VISITED: 9—/C —2
o
Pri r•a-
VISITED BY: J