GW1-2022-06615_Well Construction - GW1_20220711

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'd�LLW—SO YS 1 RUCTION RECORD(GW-D 'For Internal Use only: I �
1.vwen�;ontractor information:
t�lU•1 `.
19.WATER ZONES
Well Contractor Nam FROM TpO�Well
/ (gft. D L a I I
NC Well Contractor Certification Number T
15.OUTERCAMG fornirrlti-resW�as ORLINER rfa livable
YADKIN WELL COMPANY,INC.. FROM I To I I)IOMTRR I THICKNESs MATERIAL
ft. ft in.
Company Name r`a y �� -a a ��� 16.RJNER CASMG OR TU13ING eothermal closed-loop)
FROM TO DIAhILrM THIC10=S MATERIAL
2.Well ConsttvetianYermit#: � `�z®as��
List all applicable wall construction permits(ie.WC,County,State,Parlance,eta) ft 99 it - +�,dJ�`in. Qk- C
3.Well Use(checkwell use): ft ft. in.
W,Ater Supply Well: 17.SCREEN
FROM TO DLkrd=,R SLOT SIZE THICICNESS MATERL4L
Agricultural pMunicipal/Publfc ft. ft, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft. in.
❑IndustriallCommercial pR.esidential Water Supply(shared) Is.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEII'II:NT I%ETHOD&AMOUNT i
Non-Water Supply Well: ft. i ft. ��
❑Monitoring ❑Recovery L� it ft. e,-sl
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
I9.SAND/GRAVEL PACK tf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL ESTPLACEMENTMETHOD
❑Aquifer Test ❑StomrwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(ClosedLoop) ❑Tracer 20.3)RILLINGLOG attach additional sheets ifnecessary)
❑Geothermal(Heating/CoolingRetinn) ❑Other(explain under#21,Remarlcs) FROM TO AESCRIPTION color,hardness,so' in s Etc.)
N Ce k �� d�R�gry�z as 0 ft. ® ` ft.
4.Date Well(s)Completed: (o"J'i ' Well ID# AAP g ft
5a.Well Location: Phone # 0 Y-9 fL ft it•
K4CZ-14-, ft ft A'
FaQty/OwnerName FaciliwID#Cif applicable) ft fL
ft. ft
Physical Address,City,and Zip l ft ft. to
Era of s/f k 21.REi14ABILS
County I Parcel identification No.(PIN) ow
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^^• `" ''? KY�I'1 ��1
(ifwell field,one latliongis sufficient) 22.Certification: lPi�mvo 1 r
6.Is(are)the well(s): k4ermanent or ❑Temporary We
oftc4ffrd Well Contractor Date
By signing thisform,I hereby certdy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Wo 15ANC4C 02C-.0100 or lSA NCAC 02C.0200 Well Construction,Standards and that a copy
Ifthis it a repair,fdl oul brown well consirvc6n information andexplain the nature of the ofthis record has been provided tc the tiPe/f owner.
repairunderi2l remarkrsectfon or on the bark ofthisform.
23.Site diagram or additional vvell details:
0.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�W 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarls Box).You may also attach additional pages if necessary.
drilled, 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 69 ft) Submit this GW-1 within 3D days of well completion per the following:
For multiple welh fist all depths ifdlfferent(example-3(Qa 200'and 2Q100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water IevE below top of casing:. .r (ft)
lfwater level is above casing,vse"+" Information Processing Unit,161'7 MSC,Raleigh,NC 27699-I6I7
I2 Borehole diameter (in.) Bit Off: •4Wd 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open=Loop Geothermal Return Wells:Copy to the
(i B.auge,rotary,cable,direct push etc.) county env rental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prod ucin� yer 100,000 GPD:Copy to DWI;,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raldigl,NC 27699-I611
13b.Disinfection type: 70%HTH Amount- OZ . DATE SITE VISITED:
VISITED BY: -
Pr - - -