GW1-2022-06606_Well Construction - GW1_20220711

VITELL CONSTRUCTION TRUCTION RECORD CORD (GPI-la For Internal Use Only: C,
1.Well Contractor Information:
14.WATER ZONES I
Well Contractor Name FROM TO DrzgrnTP"mq
•ft �:;� ft
$"7Sft 6-7( 4 GPir7
NC Well Contractor.Certification Number
I5.OUTER CASING for multi-used wells ORLINFR if a [irable
YADKIN WELL COMPANY,INC. FRoM x0 DIAMETER TffiCK14Ess MATERIAL
ft. ft. in.
Company Name
/� 16.INNER CASING OR TUBING eothermaI dosed-loop)
2.Well Construction l'ermlt#: �y / V FROM TO 131OMTER IMCKNESS NtATERLIT,
List all applicable well construction permits(i.e.UIC County,State,Variance,eta) ft ft (� rap
-, ONK ;•-'' IV
3.Well Use(check well use):
Water Supply Well, 27.SCREEN
FROM TO DIAMETER"' SLpTISIZE �eISIGr(NESS MATERIAL
❑Agricultural ❑Municipal/Pnblio ft. ft. :
❑GeothMT aI(Heating/Cooling Supply) Residential Water Supply(single) ft ft, ln:` '
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 1i '`• ` ' c
❑hTigatiOIl 17Wells>100,000GPD FROM I TO MATERIAL 'EMPLACEMENTAMTHOD&AMOUNT
Non-Water Supply Well: ft
.11MO16iing ORecovery 3: �� ff• Qv` da P 3
Injection Well: �� v
ft ft
❑Aquifer Recharge OGroundwater Remediation X.
❑Aquifer Storage and Recovery175 Barrier FROM SAPID/GRAVEL PACK Crf a liable •
slinity FROM To MATERIAL'.;_ EMPLACELVM-NTMLTHon
❑Aquifer Test ❑Stomiwater Drainage &
r?
❑Experimental Technology .bSubsidenhe Control ft it
❑Geothennal(Closed Loop) OTtaoer 20.DRILLING LOG attach additional sheets ifnecessaryl
❑Geothermal(He ating/CoolingRetum) 170ther(explain under#21Remarks) FROM xo DESCRZPx[ONram�harauess,seVroek S .' srae�e
ft. ft
4.Date Well(s)Completed: to WellM'# 70 20 02 ft 6 A4 Air
5a.Well Location: Phone#_ � ,�, es�
Facility/OwnerName Vev Fe
r
ft ft �
Physical Addres�s,City,and Zip ft ft
�2 (.:[�W ea 21.REIYTARKS u,, ere:•-..
County PamelIdentification No.(FIN) �rui - " 1 ?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/iongis sufficient) 22.Certification:
io
6,Is(are)the well(s):*ermanent or ❑Temporary SignatuA of Cmlgrd Well Contractor Date
,,��&,,"" By signing thisform,l hereby certify t•hat the wdl(s)was(were)constructed in accordance with
7•Is this a repair to an existing well: ❑Yes or *D ISANC4C 02C.0100 or!SA NCAC;02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and erplain the nature of the ofthis 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:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction infoe
construction,only 1 GW is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).'You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
I
9.Total well depth beIaw land surface: 6 0a (fL) Submit this GW-X within 30 days of well completion per the following: s
For multiple wells list all depths lfdifferent(example-3@200'and 2@700�
S� (ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below tap of easing: (ft.) Infnnmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
7f�afer level is above casing,use"+'
Il.Borehole diameter; (in.) Bit Off: J.7ew 24b.For Injection Wells: Copy to DWR,Underground Injection Contml'6-uT ),i:�,,
Program,1636 MSC,Raleigh,NC 27699-1636 IN'
AIR ROTARY12.Well construction method: 24c.ForWater Supply and Open-Loop Geothermal Return Wells Ctoi `
(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 tol)WR,CCPCUA
Permit Pmgram,1611 MSC,Raleigh.NC 27699-1611
13a.Yield(gpm) a� Method of test: ��.6g
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: -
�'� _ VISITFn ray. � '