GW1-2022-00851_Well Construction - GW1_20220107

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'.Well Contracdlr Informntion:
14.WATER PONES
Well Contractor Name
FROM TO" DR3CRIPTION
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NC Well Contractor Certification Number r
15.OUTER C G for multi-cased s ORLINER d a likable
YADKIN WELL COMPANY,INC. FROM To DIAM1rrER TLL1CIQrEss MATERML
fL ift. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: PROM I TO DrsAMTao TRICIOPESS I AATERIAL ^ ,l
List all applicable well construct/on parnits rCm f11C,County,State,Variance,etc.) ft ft �,�Sd in. f !9 ` O
3.Well Use(check well use): ft ft. 7 in.
f0
Water Supply Well: 17.SCREEN
FROM ` TO DIAMETER SLAT SIZE TMCIMSS MATERIAL
❑Agricultural ❑MunicipaI/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) .
❑ )Industrial/Commercial ❑Residential Water Supply(shared n t Y
IS.GROUT t'
❑Irrigation []Wells>I00,000 GPD FROM .Irl...TO n MATERIAL. ENYVACENMNT METE D dL AMOUNT
Non-Water Supply Well: Q �j
�r ft. ft o 1 c / -j
❑Monitoring EIRecovery ft "ft• a�n • e:
1 Injection Well: F ^• ft. 3t
YJ ❑AqutibrRecharge ❑GroundwaterRemediation I J � f'
µ19.SAND/GRAVEL PACK rif applicable)
#;
Ln ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM -To MATERLAI EnfivrACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
0 ❑Geothermal(Closed.Loop) []Tracer 20.DRMLING LOG attach additional sheets ifnecessaTy)..
GJ ❑Geothermal(HeatinglCooling Rettml) ❑Other(explain u Me nder#21 oaadd FROM TO DESCaIPIION whir,Iuraaev:nU/roelc irks eh
�j//� � ft R • � ,F,l�� •
-x+ 4.Date Wells)Completed: ,Well ID# �.� /`/ R R s t ,c - C
y u §;
5a.Well Location: Phone# /d "/' `$��`53 i� ��-' ft fdi ' G
71i�OL tc s
Facr7ity/ erName Facility ID#(if applicable) j!
►� a R�/j fib.` !• 11k r� ft-
1 16 �' I V
Physical Address,City,and Zip ^ P/� 6/ `l
✓�till h1 21. S
County Parcel Identification No.(FIId) ` d' �Mt ��✓ r `' iJ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) `' 22.Certification: i t{ ;,
N
6.Is(are)the well(s):Aermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed M accordance with
7.Is this a repair to an existing well: ❑Yes or WIND 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction,Standards and that a copy
If this is a repair,fill out brown well construction hformation and explain the nature ofthe of this record has been provided to the,well owner.
repair render$21 remarks section or on the back ofthis 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 nee ed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCITONS
9.Total well depth below land surface: 462 (ft-) y Submit this GW-1 within 30 days of well completion per the foll6tvin
For multiple wells list all depths Y'&ffemnt(example-3@200'and 2 1001 P P g:
1 v
f)4 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft)
lfwaier level is above casing,use"+" Information Processing Unit,161 i MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) Bit Off: 24b.For kiection Wells: Copy`to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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 department of the county where installed
FOR WATER SUPPLY W,r, ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Q0V Permit Program,1611 MSC,Raleigh,NC 27699-I611
13s.Yield(gpm) Method of test:
13b.Disinfection type: 70%HTH Amount- OZ DATE SITE VISITED:
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