GW1-2022-06412_Well Construction - GW1_20220603

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1.Well Contractor Inforrontion: ,
d 1 s F`� 14.WATER ZONES 11
Well Contractor N e FROM TO DESCRIPTION
1 A S^ft ft.
C9 S 7 ice'J ft. ft
NC Well Contractor Certification Number i
15.OUTER CASING formniti-casedvi�eIIs ORLWF.R rfa ticable
YADKIN WELL COMPANY,INC.
FROM TO DTAML= TffiCIOVFSS MATERiAI.
ft ft I 'im
Coro an Name � �' �"
P Y ,� Py�o r�3�fS�` r 16.DMR CASING OR TUBING !eothermal closed-loop)-
2.Well Construction Permit#: d- ItUJL 2C92k ® 7,005— FROM To DIA1v1r= L THICIRMS I MATEM4L 4
List all applicable well construcllon permits(le.b7C,County,State,Variance,etc) It ft in. O '-a ^'
3.Well Use(check well use): ft. rn'
17,SCREEN
Water Supply'Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑M micipal/Public ft. Yft. in.
❑Geothermal(Heating/Cooling Supply) Nesidential Water Supply(single) ft ft in
❑IndustriaVCommercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft. �,.�`l
❑Monitoring ❑Recovery it r0 ft.
Injection Well: '�/v'
i
M ft a "
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK Cif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENThMMOD
❑Aquifer Test ❑Stormwater Drainage ft ft i
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary) r 1
TROM TO DESCRIPTION color,bardnesa sciVruck Mr.gmiu sbc' eta k p`
❑Geothermal(HeathWCoolingRetum) ❑Other(explain under#21 Remarks) ft. ft
4.Date Wells)Completed: '�Z WeII ID# ft.
70�r ft
Sa.Well Location: Phone # ft ft t r 1
33L- 6�-�S�3�
Irk
_ RaA ft ft
Feailiiy/OwnerName Facility M#(if applicable) ft ft•
4oJ' L k;Av- A f� P-i MIPAvy ft ft s .
Physical Address.City,and Zip ft ft ?7
21.REMARKSJUN
County Parcel Identification No.(P]N) �'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laUloagis sufficient) PRO",r 22.Certification: . ;' a
r' r
6.1s(are)the well(s): 03Permanent or ❑Temporary 431?grn�'i'�n-Cigthisfam,lhembycenyyihat
of C d Well Contractor Date
-l the well(s)was(were)cans6 ctedin accardmice with 1
7.Is this a repair to an erdsting well: ❑Yes or MPIo 15A NCAC O1C.0100 or 15A NCAC 02C.0200 Well Conslructlon 3Ymdardr and that a copy'
If this is a repair,fdl out known well construction bormalion and explain the nature of the of this record has been pravided to the well owner.
repair under#2l remarkr section oron the bark ofthisform. 23.Site diagram or additional Well detafl5:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pagi to provide additional well construction info
construction,only 1 GV�-1 is needed. Indices TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessMy-
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �a (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dj$erent(example-3®200'and 2@1001
i
24a. For All Wells: Original form to Division "of Water Resources'(DWR),'
10.Static water Ievel below top of casing: �� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 �1
If water level is above casing,use"+" r q
Bit Off* J r ! 24b.For Iniection Wells: Copyl to DWR,Underground Injection Control(I[TC);. Z
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,NC 27699-1636
0 AIR ROTARY
12.Well construction method: 24c.For Water Supply and Op G-Loop Geothermal Return Wells Copyto the,
'
(ie.auger,rotary,cable,direct push,eta) county environmental health department of the county where installed ; Q
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinig over 100,000 GPD:Copy to DWR,CCPCUA
/ A--
`-moo Permit Program,1611 MSC,Raleigh
;�,NC 27699-161 I
13a.Yield(gpm) 3!2— Methodoftest: � ' y ,
70%HT H cc OZ DATE SITE VISITED: t� � 2 ey
(ac.A l,•
13b.Disinfection type: Amount t`✓e/ I �:C • t
---- VISITED BY: pWS AW/,P.
i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6 2018 N;