GW1-2022-06635_Well Construction - GW1_20220711

,&NULL CONSTRUCTION RECORD(GW-L For Internal Use Only: i (�
1.Well Contractor Information: I `�
14.WATER ZONES
Well Contractor N a PROM TO DESCRIPTION
_ 72-e
NC Well Contactor CcnificationNumber 15.OUTER CASING(for mnlfi-cased'w4s ORLINER if a linable
YADKIN WELL COMPANY,INC. FROM To DL\MISTER TffiCEMSS MATERIAL
ft in.
Company Name V ��� kyq-`7���. 16.IlVNERCASINGOR TIIBING eothermalclosed-loo
2.WeUConsh-uctionPermit#: ^Q#YC.�`7- 2pP,- EOM TO DI&MX D THIc[iNrSS I MATEsiAL
List all applicable well construction permits(l,m WC,County,State,irarlonce,eta. / ft ?T ft 4p in. Ow-al
M
3.Well Use(check well use). ft ft. I�
Water Supply Well: IROM�U TO DIAMETER! SLAT SIZE THICICNrss MATERIAL
❑Agricultural ❑M�unicipal/Pablic ft• ft. in.
❑Geothermal(Heating/Cooling Supply) ( Residential Water Supply(single) ft ft. in:
❑Iudustdal/Commercial ❑Residential Water Supply(shared) 1B.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOIINT
Non-Water Supply Well: ® It. 3' ft. 6- 41_C- opap P.
❑Monitoring ❑Recovery 30 ft a>( ft m , 6D
Injection Well:
ft. ft:
❑Aquifer Recharge OGromdwater Remediation
19.SAND/GRAVEL PACK lff a llcable
❑AquiferStorageandRecovery ❑Salinity Barrier PROM TO MATERLAL EATPLACENJINTMETaOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology;t,-% . ❑Subsidence Coirtrol ft it
❑Geothetmal(ClosedLoop)";1 OTracer 20.DRILLINGLOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolidgRetmn) bother(explain under#21 Remarks) FROM To DESCRIMON rdlor hgrdness,soiVrorlc y . sue,cte.
ft'
r ft
4.Date Well(s)Completed: Well 1,4 C3� IL /l7.Q� y
5a.Well Location: Phone# W-FcIV2 176L 430 ft eW
at 57,7'fL rr.P� 9e
Fau ity/OwnerName Facility ID#(ifapplicabltr) ft ft
ovs ft. ft WE D
Physical Address,City, •d ft ft.
County Parcel ld"fification No.(PIN) - "-A
f3ei+t Qzmj1 •.n.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;",�°'';"`;"; � p-7NI MSING UNF
(ifwell field,one lat(Iongis sufficient) 22.Certification:
6.Is(are)the well(s): Permanent or ❑Temporary ertified Well Contractor ' Date
By signbng thisfonn,I hereby certify that'the wells.was(were)constructed in accordance with
7.Is this a repair to an existing well.* ❑Yes or MA 15ANGIC 02C.0100 or ISA NCAC D2C.0200 Well Construction,Standards and that a copy tt
If this a a repair,fill our known well construction information and a=plafn the nature of the of this record has been provided to the well owner. �l
I
repair under4.21 remarks section or on the back ofthisfoM. 23.Site diagram or additional weIl 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 construction info
construction,only 1 GW I needed. Indicate TOTAL NUMBER cf wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:, i
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: e7 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells rut all depths if different(exam.pre-3(n)200'and Z 00D
a
®� 24a. For All Wells: Original fbim,to Division of Water Resources (DWR),
-10.Static water Ievel below top of casing: (ft*) Information Processing Unsi;1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use �r
11.Borehole diameter: (im) Bit Off: ,671 74b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636MSC,Raleigh,NC27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open(Loop Geothermal Return Wells:Copy to the
(is.auger.rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing I ver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program41611 MSC,Raleigh,NC 27699-1611
13a°•Xield(gym) � Method aftest: � � i ass
13b.Disinfection type: 70%HTH Amount OZ DATE SITE VISITED: `�>3 p '2-Z °