GW1-2022-01030_Well Construction - GW1_20220107

t
% t;QNS TR UCTT10N RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATERZONES i
FROM TO DESCRIPTION
Well ConhactorN bO t /��
�s�y>� ft. it
NC Well Contractor Certification Number
15,OUTER CASING for siiulfl-cased wells OR LINER(if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name ea,4.Kb'-- 3-X-9-54q- -7k®S' Cool
�^ 16.INNER CASING OR TUBING( eothermal dosed-loop)
2.Well Construction Permit#:tAJA/4 e'0( -7 3 R - 2-®2-t FROM TO DIAMETER THICIINFSS I MATERIAL
List all applicable well construction permits(�e fI1C,County,Slate,Variance etc) �.! it 39 ft �� n' sD P
3.Well Use(cbeckwell use): ft ft' 1II"
17.SCREEN
Water Supply Well:
PP y FROM TO AIAMETJa SLOT SIZE THICIlT[ESs MATERIAL
OAgricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) &iesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft • ft � .
❑Monitoring ❑Recovery (� it 27 ft. Anj�45L
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVES.PACK(if appIIcable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stortnwater Drainage ft; ft.
OExperimenta]Technology ❑Subsidence Control ft ft
Cl Geothermal(Closed Loop) ❑Tracer, 20.DRILLING LOG attach additional sheets ifnececsa
❑Geothermal(Heating/CoolingRetoin) ❑other(explsinimder#21 Remarks) FROM TO DESCRIPTION color,hardness,=Vrotictype,graio,i:,eta
0
4.Date W (s)Completed: ' Well m# AAO 6 J 7 PG R 5-0 K &I-epor IhI Gigrt.-kr
5a.Wen iuoc oo t� Phone # {—t�l� D, cad
Farality/Owner Name Facility ID#(if applicable) Q' Je
-
177
4W Jur-
PhysicalAddress,city,and zip 3 006- As"TL Au. Sig JAN 7 2021
7.1.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one IaUlongis sufficient) 22.Certification: "
x f�y W
®� r
6.Is(are)the well(s): Wrrmanent or ❑Temporary Sivgnure of CeKlied Well Contractor Date
By signing thisform,l hereby certify that the well(s)was(were)constructed in AcQYdance with
7.Is this a repair to an existing well• Dyes or 04o 15A NCAC 02C.0100 or 15A NCAC 62C.0200 Well Construction Standards°ntid that a copy
If this is a repo/r,fill oui Imawn well construction informatton 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. r ,-
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 needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlm Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: •a3 (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifemni(example-3@201r and 2®1001
rD a 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
11.Borehole diameter- (in.) MOM 'UO3 24b.For Injection 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 WELLS ; ����/.� 24d.For Water Wells producin119 over 100,000 GPD:Copy to DWR,CCPCUA
(gp ) Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: �f
13b.Disin Q 13a.Yield m
70%HTH y OZ D SITE VISITED: ® � � -2
�-An a-txne. Amount: �
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