GW1-2022-01041_Well Construction - GW1_20220107

r-„�...•-JHERMAL (1(1EL.tl;: CONSTRUCTION RECORD
WELL CONSTRUCTION ION li ECORD " l or2nterna]Use ONLY:
This form can be used for single or multiple ivells
�.WelI Contractor Information:
row n IR WATER ZONES
FR0" .TO DESCRIPTION
Well Contractor Name a'v ft. a t 1 ft. 10,
A ts�')
S6fl:
NC Well Contractor CerUcatiou Number 15.'0UTER CAS114 for multi-tzse ,V,Us OEM- if lion likable
M• TO CRIER TH1Q MAISMIAL \
Yadkin Well Company, Inca
Company Name 16.INNER CAM OR•TU 1NG! eatllermal closed400
x / ! FROM TO DIAMETER TBICIUMSS MATERIAL
2.Well Construction Permit K: C ('1 t Q b t, ft• Z3 ft "� M n ! Ar. j
List all applicable well cautnrctiort permits(.e.County,Stafe,Farfancz,efe.)
ft. ft. SitlY
in.
3.Well Use(cheep well use): 17.SCREEN Z
Water Supply Well:
M TO PETER SLOTSIZL HICIOVESS 1MIATERIAL
❑Agricultural OMunicipal/Public o.
❑Geothermal(Heating/Cooling Supply) ❑Res.idential Water Supply(single) ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
MON TO aiATEML rAMPLACEM%NTNIETI10D&MOUNT
Nou-Water Supply Well: _ J
mmonitorinp
is
_
ft ' ft
b +' - _
.L
tI�tJechop'tiVtili• �, .: FRO•1 TO. - _.. _..14Li ...
ft '
1❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK d applicable)
'bAquif6r Storage and Recovery ❑Salinity Barrier TERIAL. -."-- ' EnipL�CCMtIDf1 MRTAOD
OAquiferTest OStormwaterDrainage
❑Experimental Technology ❑Subsidence Control• "' =
DRILLING LOG attath-adAitian`alsbe`etsifaecessa
v6eot icrtilah(Ciosed Loop) rW"'o ❑Tracer FROM '' : '70 DESCR2T10L1 eo1ar hnrdness soil/rods type,train site etc.
❑Geothermal(Heating CoolingRetttm ❑Other(explain under#21 RemaAl
rks ' �'
4.Date.I'Vell(s)Completed: ` �'t+ L'( Weu ma.AArQ-01
52.Well Location- Phone .num.berQ ec 1.i W��r Fa `:_'' t — l
it tt. zq fL ' ' `e. lift f i.
VVfI1'tP- ('t�h r+o '�1"3
: . .ft ft
Facility/owner Name FacilityID6(if applirable)
INC, 11991 ft. it. C
Physical Address,City,and Zip 21.REbrARKS v
County Passel Iden6ficatioallo.(PIN) Of 100 s ner :Bore' lit / l ' 1]late' !Of loops
5b.Latitude and Longitude in-degrces/miuutes/seconds or decimal degrees: 22•Certification L1V
(ifwell field,one latlloog is sufficient)
Signature of Certified Well Contractor Date
6 Is(arc)the well(s): gi�ret'luanent or ❑Temporary gy sig,ring this jornr,I hereby cn-t6(hot the we!!(s).u•as.(werel.constructed fit accordance
wllh 15A NCAC 02C.0100 or ISANCAC 02C.0200 Welt Corrstntctio)i Sttmdards and that a
7.Is this a repair toanexistingwell: 17Yes or i/o copyof flits recordhasbeeirprtnrtdetl.(orheNellotidncr. .
If this is h forntarton mrd ecplafq the naltn:e of fhe
`l'epair teader9.`21 renmrbsection or on the back of rhisfam. 23.Site dice am or add tionahwelliretails=;,....;:.,; -
You-m use t]ie_back of this.&ge to iovide:additional well site details or will
8..Number•.ofwclls,.constructed:. . i construction deWls. You may;aTsdittacliaddititinal-piges if-necessary.
For lnulliple injectiarr arnon iraferaftppl rwells ONLYwfdr the sate cousbstctiart,ymt can, -
submitoneform. -- SU$MITTALINSTUCTIONS-.,;
9.Total well depth'below Iand surface. �7 00 (ft) 242.:For W All ells: . Submit,this form within 30 days.of completion of well
For rnulaple wells list al!depths ffdierent(example-3©200'a»d 2©1003 construction to the following
10.Static water level below top of casing: ' I (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,we"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (iu.) 24b.For Iniection Wells: In addition to_sending the form to the address in 24•a
above, also.submit a copy of this form within 30 days of completion of well
12.Well coustruction method: Rotary constmctionto the following:
(i.e.auger,rotary,cable,direetpush,eta) Division of Water Quality,Underground Injection Control Program, SK
o K
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Service Center,Raleigb,NC 27699-1636 J`
13a.Yield(gpm) �.� Method of test: rT� a'r 24c.For Water SupolyL Injection l•Yells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
f p': completion of well constriction to the cotutty health department of the county
IA.Disinfection type: HTH Amount: where constricted.
F
/wA d 7•N
Form G W-1 Nortlr Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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