GW1-2022-06641_Well Construction - GW1_20220711

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WELL CONSTRUCTION RECORD(GH-11 For Internal Use Only: I �
1.Well Contractor Information: l
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Well Contractor Name DESCRIPTION
t- ,�:psi 367 AM-
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NC Well Contractor Cal ficationNumber t orniuld-cased ells OR LINER ifa licableYADKIN WELL COMPANY,INC. T RAMTER TI3 MiE65 MATERIAL,
ft. � in.
Company Name
i' , �J r 16.INNER CASING OR TUBING eotherma]rlosed-loop)
2.Well Construction Permit A: �\ M 0 I U 13 IG� FROM To DRAhIETER I THICIaMS MATERLw
List all applicable well construction permits r,a LUC,County,State,Parlance,etc.) --2 It ft 'JX in. ,/r
3.Well Use(checkwell use): ft ft. in.
SCREE N
Water Supply Well: FROM TO DIAMETER SLAT SIZE TEaCICNESS MATERIAL
❑Agricultnial ❑Municipal/Public ft. ft, in.
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM I TO MATERIAL. EMPLACEM ENTTIETIiOD&AMOUNT
ZWterSupplyWell:
ring ❑Recovery M ft.
Injection Well:
'
❑Aquifer Recharge ❑GroundwaterRemediation ft. ft. P Pr 1=
19.SANDIGRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier MOM TO MATERIAL, E OD
❑Aquifer Test ❑Storrawater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control it
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets'.t, a O7 • _• �I�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under##21 Remarks) FROM TO DESCRIMON cc ni•,n,cdaesi,smt/rnck sae,cra ~
ft. 3® ft. S C/ r
rr�� b '
4.Date Well(s)Completed:S-26=Z Z- Well ID#AA P v y2� 3 C� ft' J ft. 71-6,7
-
5a.WellLocation: Phone # /tS It /111) ft' 6'-M' fs-4
o L 0 M w-, oil ft :11
Facility/OwnerName PacilifyM9(if applicable) AS- ft' j�°� ft V Jr.
zo jj I t h— 47020 /7 2,
ft Z 31• �' f! 'e.
Physical Address,City,and Zip 2 3 r ft 2 S—v
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®YLUM�A/^ � �`//�"c`�`,
County ParoelIantificationNo.(P
ru�¢ CPYJ /�L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 3 LIX / 05. ,4,
(ifwell field,one latllong is suffidrut)
22.Certification:
6.Is(are)the well(s): D'ermanent or ❑Temporary gnat=of Ceitified Well Contractor Date
By signing thisform,I hereby cerfify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well., ❑Yes or PIo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill aul known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under f21 remarks section or on the back of thisform.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarim Box).,You may also attach additional pages ifnecessary.
drilled: _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U`� —(ft Submit this GW-1 witbin 30 days of well completion per the following:
For multiple wells list all depths lfrUfferent(examp1e-3@200'and2Ql00D
s 24a. For All Wells: Original ;form to Division of Water Resources (DWR),
10.Statiewater level below top of casing: 75 (ft.) Information Processing Ulric 1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+" i
11.Borehole diameter: (in.) Bit Off: 24b.For Injection Wells: Copy to DWI,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Op en-Loop Geothermal Return Wells:Copy to the
(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 moducin glover 100,000 GPD:Copy to DWI,CCPCUA
13a.Xield(gpm) Method of test: C Permit Program,1611 MSC,Raleigh,NC 27699-1611
a i I
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount:
PrT ce__
VISITED BY: