GW1-2022-06646_Well Construction - GW1_20220711

LVEl LL CONSTRUCTION RECORD q'GW-13 For Internal Use Only:
1.Well Contractor In_fornntion:
U 14.yyATER ZONFS I '
TROM TO DFSCPIPTION
Wei onhac- nine o ft, ��� ft. M
�+ °ft } fill% C0/ —.�®�
NC Well Contractor CertificationNumber 15.0 UTER CASING(forniulti-used, ells ORLINER if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TLIICLOVES5 MATERIAL
fL ft in.
Company Name
A� 16,INNER CAS NG OR TUBING euthermal dosed-loop)
2.Well Construction Permit#: ` FROM TO D MTER TffiCItPTESs HATERIAL.
List all applicable well construction permits(ie C,County,Slate,Irariance eta) �J it a yP in. .S�I�, ( vc
3.Well Use(checkwell use): ft. ft. in.
Wa r Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMCICNESS MATERIAL.
ulk9doultural DMuiiicipalRublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ntial Water Supply(single) ft ft. in.'
❑ludustrial/Commercial. OResidential Water Supply(shared) 18.GROUT
❑Irrigation []Wells>100,000 GPD FROM TO 'MATE UAL m2LAcEmr IT1%TZTHOD&AMOUNT
Non-Water Supply Well: ft. ft. ;A
❑Monitoring [7Recovery ft ft ��! S/oY �J
Injection Well: ft.
❑Aquifer Recharge OGrrnmdwater Remediation
19.SANDIGRAVEL PACK{(if a lirable)
❑Aquifbr Storage and 116caveIy` 088&*Banier FROM TO MATERIAL >:n,1PLACCMINTMETSoD
❑Aquifer Test; "ClStormwater Drainage
[7Experimerinl;Technologp ❑Subsidence Control ft ft
QGebtharrimaT(Closed Loop) _ ', ❑Tracer 20.DRILLING LOG attach additional sheets if necessa '
[]Geothermal(Heating/CooliugRetain) ❑Other(explain under621 Remarks) FROMxo nEscRlaTlox�mr,hardness,:eiVrock a min sue eta
4.Date WeII(s)Completed:'F7'' '` "WeII ID# ( '06 , ft. rY1&a 5,
52.Well Location: Ff laCle k M;M7:- 1� tt fL
ft IL
Facility/OwnerName FaralitylLlfk(rfapplicable) ft
4�T2`ftidrEJ`[�ir/� Gf IiG�� �" ft ft P `!P`b
Physical Address,Citn and Zip � tr
I.CL� 21.REMAPM juL
County PamelldentificatioriNo.(PIN) 30/ ^30 raokz-y� e-op,- ,,-
5b.Latitude and longitude in.degrees/minutes/seconds or decimal degrees: ^" "' ^ `' '�� '•t�I IN111
Ifwall fief one lat/loagis"suffci6nt ". I di V aotr� �
r d, ) 22.Certification:
N � A l•,Ui-1� W
6.Is(are)the well(s): dIrmanent or ❑Temporary Sigo Certifi ell Contractor Date
�J/ By signing thisform,I hereby verb that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Q& ISANGAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Iythis is a repair,fill out known well cons.truction information and explain the nature ofthe ofthis record has been provided to the well owner.
repairunder121 remarkrsection or an the backofthisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop GeothermalWells having the same You may use the back of this page'to provide additional well construction info
(add See Oves'in Remarks Box).You may also attach additional pages if necessary,
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:, I J 24.SU13MrrraL.INSTRUCTIONS
9.Total well depth below land surface: a-d-I (R) Submit this GFV-1 within 30 days dwell completion per the following:
For multiple wells list.all depths Ifdifferent(example-3@200'and2Q700
1D.Staticwater level below top of casing: (� (ft) 24a' For All Wells: original form to Division of Water Resources (DWR),
Information Processing Uni%1617 MSC,Raleigh,NC 27699-1617
Ijwoter level is above casing,use"+"
Bit Off: ° 070 24b.For Injection Wells: Copy to'DWR,Underground Injection Control(IUC)
If Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY !
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le,auger,rotary,cable,direct push,eta) county environmental health departdrent of the county where installed
i
FOR WATER sup—PLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit P-gram.1611 MSC,Raleigh,NC 27699-I611 y
13a.Yield(gpm) 1 Method of test: °� !' «aft✓ P41T(ti'Pe `
13b.Disinfection type: 70%HTH Amount OZ
DATE SITE VISITED:,
r_, _� VISITED BY: � r _