GW1-2022-06385_Well Construction - GW1_20220603

+C�I�l_ For Internal Use Only: i
1.Well Contractor lnforrnatioir. h
j ,
S end :(iJa�'�c.►r+S 14.WATEItzolvEs�_
FROM TO DESCRIPTION
Well ConhaclorName ft /so ft
Jo"GPrn
7 �4,Sa A ft :14FO fl-
pin j
Nc well Contractor Caitifioation Number
a M� 15,OUTER CASING for multi-cased wells ORLINER if a licable
, •FROM TO DIAIIIETER TffiC[Q1E55 MATERIAL
YADKIN WELL COMPANY;INC.
ft ft. in.
Company Name 16.BHNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: �ij/'( FROM xo Dw im THICKNESS MATERIAL
Lis/all applie~ab/e ii,ell constructian permits(Le ,County,'State,Varionck,ata) /ft 4 3 ft s� in.
3.WelLUse(check well use): L R ft is v
17.SCREEN s"
Water Supply Well: i FROM TO DL WIL"ER SLOTSIU Tluga IISs III MA:I'ERL1L
Agricultural OMlmicipal/Publia,i ff. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft: tt. ;n. V '
01ndustrial/Coammercial ❑Residential Water Supply(shared) lg.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMBMOD&AMOUNT
Non-Water Supply Weil: + + ' . . ft' AJ ft. &Jeiy ovPtd
❑Monitoring ❑Recovery 44 ft e71
hij@ction Well: ft. R
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVF.LPACK da licable r
❑AquiferStD4ge and Recovery ❑Salinity Barrier FROM TO I MATERIAL. -%MPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage it ft
❑Experimental Technology ',OSubsidenca Control ft ft m
OCeofhermal,(Closed Loop) ❑Tracer 20.DRILUNG LOG attach additional sheets if necevsa a y
❑Geothermal(Heating/CooliugReturn) bother(explain under#21'Remarks) FROM xo DESCRIPTiONC9lerlrardaessSeiVroc3c a6GLCtL
4.Date Wells)Completed: S, Q ZZ Well ID# .. O. '^_� 13 ft Ab
on:W l�ll� 33nho
Facility/OwaerNemc FacilityID#Ciifapplibeblo) ft ft (1
ft fL
Physical Address,City,and Zif {
County ParcelIdanto5oatioallo.(PIIl)
5b.Latitude and longitude in degrees/minuttilseconds or decimal degrees:
tfwellfiel one is sufficient i�? ,^,, ? I,f`�►�
(� d, g ) 22,Certification (�, {:�;%�ii�ii�r�t�Pc��a
f N W 41?,Z
� .
C Aipt.
of C ed Well Contractor Date
6.Is(are)the well(s): ermanent `..or ❑Temporarg r V`
- By signing this form,I hereby certify ihat the we (s)was(were)constructed in accordance with
`` }� ISANCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction SMandards and that a copy (\
7.Is this a repair to an existing well: ❑Yes or �G'o �_. �1t J
If this is a repair,fdl oui known well construction information and icTlain 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 fatal: `
ri 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info n�
c For Geon,o only
1 OW-1
or is n Closed-Loop I Geothermal Wells having the same (add'See Over'in Remarks Box)i You may also attach additional pages if ne6essary. V.
construction,only 1 GW 1 is needed, Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: e� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdierent(emmple�and 2®1001
24a. For All Wells: Original!form to Division of Water Resources (DWR),
10.Static water level below top of casing: S (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ,
3 t{pff; rj. 9.4b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in AIR ROTARY )
I Program,1636 MSC,Raleigh,NC 27699-1636
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 ONLY: 6r V
24d;'Bor Water Wells producinaiover 100,000 GPD:'Copy to DWR,CCPCUA
i Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
70%HTH OZ DATE SITE VISITED:
13b.Disinfection.type: Amount.
VISITED 13Y