GW1-2022-03389_Well Construction - GW1_20220315

L CONS RUCTION RECORD(G -1) For Internal Use Only:
1.Well Contractor Infornrntion:
Chew le 14.WATER ZONLtS
WellConttactorName FROM To DESCRIPTrON
�►ft. C ft-
t o M
Ne Well contractor Certification Nmnber � . S ��
15.OUTER CASING form ti-cased w� LINER d e ucable
YADKIN WELL COMPANY,INC. FROM TO nIAz,1>rrER TH EKNESs MATERIAL
ft ft
Company Name 16.DOUR CASING OR TUBING ebthermal closed-loop)
2.Well Construction Permit#: FROM TO DTAhC= TffiCIams MATERIAL
Llst all applicable well construction permits(tie.LUC,County,State,Variance,etc) ft- it sv in. r
3.Well Use(check well use): R ft' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMSPER SLOT SIZE THICKtrMSS MATERIALCIA
xgpculturel ❑Municipal/Publio ft. ft. in.`
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft g,
❑IndustriaYCommemial ❑Residential Water Supply(shared) 18.GROUT
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTIMETHOD&AMOIINT
Non-Water Supply Well: ft 1' !?.i/y "G
ll
❑Monitoring ❑Recovery ft. 3- ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDramage fL ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILL1NG LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRD IION color,hu-dnen,soll/mcklype,gralu s6t eta.
f ft I bG'ft Sig fi
4.Date Well(s)Completed: --I t- WUID# -130 IOrft' 10 iti W4 j4L �. e6f k a�
5a.�Well
Location- �� Phone �3L`':3��'�I��o p r ft.
19'ok"ff d i
� 11(q,
I G.� l—L_
Facility/OwnerName Facility M#(if applicable) Y ft. it M WED
C
Physical Address,City,and 4 � �3"�� MA
A!`!" �.g,ny 2L xEMARxs
County —� Parcel Identification No.ami)
, , ,.AVMPIRJrE;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/loagis sufficient) 22.Certification:
34/ Z Qt � ` N
6.Is(are)the well(s):*ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certjfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15ANCAC 02C.0100 or I5ANCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of fhis record has been provided to the well owner.
repair under#21 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 GW 1 ispeeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled; G ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y Submit this GW-1 within 3D days of well completion per the following:
For multiple wells list all depths ifdffferent(erample-3(a)200'and 2©100)
4 i
Lid,
ft 24.',For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,161R MSC,Raleigh,NC 27699-1617
Ifwaterlevel is above casing,use"+"//
f Borehole diameter CO (�) Bit Off: �\ ,�8� 24b.For.injection Wells: Copy to DWR,Underground Injection Control(IUC)
Progra1n,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 2`4c.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 ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA C
Permit Program,1611 MSC,Raleigh,NC 27699-1611 95;
13a.Yield(gpm) V Method of test: su
70%HTH ? OZ. DATE SITE VISITED:
.13b.Disinfection type: Amount: