GW1-2022-06634_Well Construction - GW1_20220711

`V t3,CONSTRUCTION RECORD�+L4 J�-1� For Internal Use Only:
1.well Contractor Informntion:
14.WATER ZONES
FROM TO DESC 110N
Well ContractorN eo
g
51� �� O, d ft. ft I Gli'
NC Well Contractor Cedification Number 15.OUTER.CASING
FROM To fornti-cased RTffiCKNESS acable
DIMTwll MATE RAL
YADKN WELL COMPANY,INC-.
ft. ft. in. k
Company Name Y Ar F ��-
�� �g c® 16.11Y1sIFR CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: ��� Ns®�+ -�'��Z FROM TO DIAMETER THIcIOvrss 14
List all applicable well construction perrnjts(i,e.UIC,County"State,l-arirmce,air) 41 ft /C7 ft •;S , � r �
3.Well Use(checkwell use)' ft. ft. m.
7.SCREE,N
Water Supply Well: FROM TO DIAMErL'R SLOT SIZE THICrilYL+5S MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. s ft f�G�, e r!efe
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft %
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK d'a licaLle)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL r PLAC1:=NThMrJ(OD
[]Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnemsa
❑Geothermal(Heating/Coolin/gRetum) []Other(explain undeer#221 Rematics) FROM TO 9, ft DcCTiOx color,hardness,s°svr°ctr ,G •= siu,etc-
4.Date WeU(s)Completed:( �'a�WeIIID#4 AP- 0-7 z ® ft ,./(Gam®• fL .�,5•l
5a.Well Location: Phone #J7 -- Q.-/ 7 -. �'3 ft /®g /71
ft I It sloa fill,
Facility/OwnerName FaciUlyMA Cif applicable) �/ ( aj B �a f� fa"1�1;•i'�--
^� ft. ft
ft if.
Physical Addrrss,City,and Zip
21.REMARKS t" ram°
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
JUL11 2022
(Twell field,one brt/longis sufficient) 22.Certification:
�r:� :7ov130 Pi,0r,; i5, dZ
6.Is(are)the well(s): f3Permaneut or ❑Temporary Si re of Cmt&Ed Well Contractor Date
_ By signing thUfarm,I hereby cert�that the wa11(s)was(were)constructed in accordance with
7.Is this a repair to an existing weII: ❑Yes or f"R`lo ISANCrIC 02C.0100 or I iA NCAC 02C.0200 Well Construction Standards and That a copy
If this is a repair,fdl out]mown well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under-921 remarks section or on the back of this form.
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 additional well conshuction info
construction,only 1 GVY-1 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
9.Total well depth below land surface: r+�iLJ� (ft) Submit this GW-1 within 30 days dwell completion per the following:
For multiple wells list all depths if different(example-3©200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: Bum 4.0/0 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27.699-1636
12.Well construction method: AIR ROTARY
r e auger,rotary,cable,direct push,etc. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i p ) county environmental health department of the county where installed
FOR WATER SUPPLY WEIJA ONLY: i
24d.For Water We]Is producing over 100,000 GPD: Copy to DWI;,CCPCUA
13a.Yield(gpm) / Method of test: i ried.t49 Permit Program,1611 MSC,Raleigh;NC 27699-1611
70%HTH .�
13b.Disinfection type: �
Amount: r Z DATE SITE VISITED:
_I� - VISITED BY: