GW1-2022-01799_Well Construction - GW1_20220214

- ICONS RUCTION RECORD('ice 'W-1) For Internal Use Only:
1.Well Contractor Information: y
.f (I 44X t y✓ �I�U jA/i7 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3o 3 & A RECEIVED 29� -all It � -9-
NC well Contractor Certification Number ❑ ��
f tD 4 ZnZZ 15,OUTER CASING for multi-cased wells ORLINER if a Ucahle
YADI4N WELL COMPANY,INC. FROM To DIAMS[ER Tffi MATERIAL
���nFrucMeewig ft. f~r in.
Company Name i Q 16.E4NER CASING OR TUBING feetithermal r]osed400
2.Well Construction Permit : R 1N L a 02 I 0 2 7 n 3 FROM I TO DIAMETER TfaCft MS MATERIAL
List all applicable well construction permits rLe.UIC,County,Slate,Yarionce,etr-) ! 7 O ft 6 VAV in.
S - ?I &C.
3.Well Use(check well use): ft I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETi It SLOT SIZE TMCI NESS MATERIAL
❑Agricultural ❑Municipa]/Public r ft ft. in.
❑Geothermal(Heating/Cooling Supply) -tesidential Water Supply(single) R ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Inlgatlon ❑WellS>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. fl. a
[]Monitoring ❑Recovery 3 it .2 1 ft. B� t x Y2
Injection Well;
❑Aquifer Recharge ❑Groundwater Remetiiation ft fL
19.SAND/GRAVEL PACK(if a Ucable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL. EN171ACEMIINTMEMOD
❑Aquifer Test ❑Stormwater Drainage ft.
I F_
❑Bxperimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neonsa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#l21 Remarks) FROM To DESCR=ON color,hardnesr,sot/rock in sae,etc to
"' 70 R. ca.'t (�
4.Date Wells)Completed: ' 1"..2 Wru iw AV"017 70 R• 1-4A j
5a.Well Lo )Wf�frt V-one # 33f•�01�''.ZOo
�« �- (/�•�-t�ls _--�e'-NJG 9�S1�• ft ft
Fsctlity/Owner Name Facility M#(if applicable) ft- R-
'7!l lea y cr h'dt ft. ft G
Physical Adds,city,and Zip it ft-
Su,r r -� rC let-County P cation No.aW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaViongis sufficient) 22.Certification;
3i� LTA! 516CO N _�90 JE qS0 W / ` 1 -2dz
6.Is(are)the well(s): #ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby ceri fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Pfo 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction SYandardr and that a ropy
If this is a repair,fill out Imown well construction hiformation mfd explain the nature of the of this record has been provided to the well owner.
repair under it21 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 needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S6S' (it.
For multiple wells list all depths felii Brent(example-3@a 200'and 2@1000 ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6 6 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ( ) Bit Off: .(�(� 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
(Lt.auger,rotary,cable,direct push,etc.) county envrronmenta]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
m 13a.Yield(gp ) Method of test: a0y Permit Program,1611 MSC,Raleigh,NC 27699-1611
F��^
70°/ HTH (:7I ,r3 OZ DATE SITE VISITED: ! `l - '.� V •2
13b.Disinfection type: ° Amount:
�► � yB R� �1S 1�
Pr7 ce. VISITED BY:
Farm GW-1 North Carolina Department of Environmental Ouality-Division of Water Resources a