GW1-2022-03398_Well Construction - GW1_20220315

CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information: F;
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
fL
3s-Li?_ Q �� ftft. ��7� fL Gl'
NC Well Contractor Certification Number is.OUTER CASING for mu7fi-cased vveDs ORL7TTER d a h'cabie
YADKIN WELL COMPANY,ING. FROM xo DIAME18Ii THrt�TEss tyrAJUAL
Company Name
16.DINER CASING OR TUBING(geothermal rlosed400
2.Well Construction Permit#: d75:5K-3 FROM TO DIAMETER TEICKMS MATERIAL
List all applicable well construction prarnits ec.UIC,County,State,Yariance,etc) fl 1t S 13
3.Well Use(check well use): ft' R' in.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
OAgricultural ❑Municipsl/Public it. ft. in.
❑Geothermal.(Heating/Cooling Supply) Pesidential Water Supply(single) g, ft.
❑Industrial/Commeacial ❑Residential Water Supply(shared) 1B.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 40, ft' ft. Y' "l{" �C4" t uee
OMonitonng ❑Recovery to ft XL ft
Injection Well: ft fL
❑Aquifer Recharge ❑Groundwater Remedistion
19.5AND/GRAVEL PACK Ofapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. R �..\
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.D7tII7I1VGLOG attach additional sh a
❑Geothermal eatin Coolhi Retum ❑Other(explain under 421 Remarks FROM To DascRiPTIo o. sues o e:ae e[�
4.Date Wells)Completed: t ` I ��WellID -0 ft- ES� ft j .1; s S 20
sa Well Location: Phone # :3 -33� �G fL
s� /'
Val fr4L�r{c�• �I10 W/�� ft /a!Q"✓Is D�e-
T I"1. , .-r. . ,t^
Faality/O Name Facility M#(if cable) 79 ft' 011 fL
0/ �` ✓v�► v
Physical Address,City,and Zip n �� ft j 3 d ft
o 21.REMARKS Cof6ty a Parcel Identification No.(PIN) 1319 ~ `�2
M` -&7 5 l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lA/�`� '� '� 'r -,--`
(ifwell field,one latilongis-nfficient) 22.Certification:
6.Is(are)the well(s): ditermanent or ❑Temporary Signature of Certified Well Coutractor, Date
By signing thisform,l hereby certify that the well(s)was(were)constructed m actort6ce with
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and Mist-a`etipy.
7.Is this a repair to an existing well: ❑Yes or ° 0
Vfthis is a repair,fill out brown well construction information 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 thisform.
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 additions]well construction info.
construction,only 1 GW-1 is nee ti. Indicate TOTAL NUMBER of wells (add See Over in Rcmazi Box).You may also attach additional pages if necessary.
drilled: ` Q \ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C7 03 (ft.)
For multiple wells list all depths ifdifierent(example-3(c�200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following.
� r
�0k 24a. For All Wells: Original form to Division of Water Resources~(DWR
ft );
10.Static water level below top of casing: ( ) loformation Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwaler level is above casing,use
11.Borehole diameter (�) Bit Off: ✓ ' 1 f/ 24b.For Injection Wells: Copylto DWR,Underground Injection Contiol
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Opel-Loop Geothermal Return Wells:Copy to the'
(it.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/ { Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 Method of test: �G✓ o `v/ -
13b.Disinfection type: 70%HTH Amount t OZ DATE SITE VISITED: � ��l J.-72, 444