GW1-2022-00952_Well Construction - GW1_20220107

n
T CONSTRUCTION RECORD (GIV-1) For Internal Use Only:
1.Weil Contractor Information:
_
'50C)LI V .S 14.WATER ZONES
Well Contactor Nam FROM TO I DESCRIPTION
s+it �-
NC Well Contractor Certification Number J g0
I5.OUTER CASING for multi-csise s ORLWER d a lirabk
YADKIN WELL COMPANY,INC. FROM To DIAMETER THIrSONE65 MATERIAL
Company Name
y� 401 P ft. $, in.
S� Xr � 3 G '
'^V� 16.INNER CASING OR TUBING eothermal closed-loop) •�
2.Well Consh uction Permit#: I?P k L 2 a It ��Z �� FROM To DIAMETER T]3ac= s MATERIAL
Lis/all applicable well construction pem�nils(ie UIC,County,Slate,Variance,etc) ft 3 ft in Dr_
3.Well Use(check well use): R ft. in. r
Water Supply Well: rnO i�L TO DIAMETER SLOT SIZE THIclmss MATERIAL r
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ,residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Rrsidential Water Supply(shared) 18.GROUT p
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT V°
Non-Water Supply Well: O it fL {� 411%�As O 0
❑Monitoring ORecovery it �' ft. 3 JV�I U t/ T-
Injection Well: ft. ft•
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVES.PACK ff a lirable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTM, OD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if nececsa
❑Geothermal(Heatmg/Cooling Rebun) ❑Other(explain under#21 Remarks) FROM To DFSCRIPTION color,hardness,saii/rork ux sae,etn .�
fr. 71r ft. Jo.L
4.Date Well(s)Completed: I/�- k-2r Well m# W-7tD 9 & 3 W �.sJ ^ rpm M3
A4A I 1A e ° 4
�Sa?Well Location: Phone # ; (o• �4�' ft a {b
V 1 f' 0"d�i�w'C t y ft. ft
Facility/Owner Name Facility ID#Cif applicable)
ft. ft
Physical Address,City,and Zip
ft it F (r" r '' p,(
9WVV
21.REMARKS jAN
County Patoe]Identification No.(P3N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwa field,one lat/longis sufficient) 22.Certification: ,^'' r• =t,:'-i'r'''
Z5s_�6 N f5 o e 2-9'. W�7
m
6.Is(are)the well(s): WIrmanent or ❑Temporary re of CcASed Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(Were)constructed in accordance with
7.Is this a repair to an emusting well: ❑Yes or ePTo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction,Standards and that a copy
If this is a repair,fdl out brawn well construction bl(ormailon and explain the nature of the of this record has been provided to the well owner.
repair under f21 remarks section or on the back of this form.
23.Site diagram or additional well details: LS
8.For Geoprobe/DPT or Closed-Loop`Geothermal Wells having the same You may use the back of this page to provide additional welt construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remaria Box).You may also attach additional pages ifnecessary.
drilled: / 24.SUBIVII'TTAL INSTRUCTIONS
9.Total well depth below land surface: i?" f Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdiffcmnt(example-3(a)200'and 2@1001
lo ft.
( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level/s above casing,use"+"
11.f Borehole diameter (in.) Bit Off: C)
cOly 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IU
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
(ie.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
1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 4P�L Method of test: 4
7b%HTH`1e•- / OZ DATE SITE VISITED: A
13b.Disinfection type: Amount
VISITED BY: wlo7 A