GW1-2022-00947_Well Construction - GW1_20220107

E-CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inform
atio
n:
• ,O d`l'1 [ • �V\�1.S 14.WATER ZONES
FROM ITO I DESCRIPTION
Well Contractor N�
�S'7�� �, ' a' rrWt
NC Well Contractor Ce ificationNumber 15.OUTER CASING for multi-rased wits)ORLIIQER if o ticable)
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THIQOiEES MATERIAL
ft ft in
Company Name - 2- ® -7 16.INNER CASING OR TUBING(geothermal closed-loo
✓e/°j' Z�:1.1 O 1 FROM TO I DIAMETIM TffiCICNESS MATERIAL �+
2.Well Construction Permit#: (rti J
List all applicable well construction permits(La.171C,County,State,Yarlance,etc) / It 9 It
'�,=i°' dRoLG
3.Well Use(checkwell use): ft ft. in.
17.SCRELtN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIIICIMSs MATERIAL t
❑Agicultaral ❑Municipal/Public ft. ft. in. !--
OGeothennal(Heating/Cooling Supply) °residential Water Supply(single) ft. ft. in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTI%MTHOD&AMOUNT
Non-Water Supply Well: ft. ft. tom, Q�/F��
❑Monitoring ❑Recovery it M pov
lnjection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
I9.SAND/GRAVEL PACK da livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL M&PIACLMENTMEMOD
❑Aquifer Test ❑Storrawater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if nececsa
❑Geothermal(Heating/CoolmgRetum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness WV-rktype,grzftskr,etc
ft It 4-ft d
4.Date Well(s)Completed:/,' Well ID# A .t° l', - ft <t A'! �,S idyll'►
5a.Well Location: Phone #32CP M_ '7a ft. ft.o�
ft ft
/� /`Zr� ifp
Facili Owner Name / Fedliiy]D#(if applicable) ft ft
f//�4 Pea 6! Y��� RA �/`' iy ft ft
Physical Address,City,and Zip t2 70 3 f�j ft ft.
,;o r r y t� 21.RETSARIGS
CountyI Parcel Identification No.(PRa) J A N L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcU field,one lat/longis sufficient) 22.Certification:
6.ls(are)the well(s):�Permanent or ❑Temporary SiaKcofC ed VUTColltractiir, Date
Byslgning thirform,l hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or >00 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
ythis is a repair,fill out known well construction information and explain the nature of the of this record has been pravided to the well owner. z
repair under 421 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlm Box).You may also attach additional pages if necessary.
drilled: U 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following: 0For multiple wells list all depths!f different(example-3(a)100'and 2©100D
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
lfwaier level is above casing,use
Il.Borehole diameter- C. (in,) Bit Off: . 24b.For 11 iection Wells: Copy to DWR,Underground Injection Control (TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1�
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA t�
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm), 5a Method of test: j
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED�J/-/7 Z.I
TY, _ VISITED BY: VG7