GW1-2022-06932_Well Construction - GW1_20220603

�•' jp�gT ►(jC��ON RECORD (GW-11 For Internal Use Only: J
1.Well Contractor Information:
3exrtl 'cis 14.WATER ZONES I
Well Contractor Name FROM TO DYSCRIPTION
aysa�a ft Aso�� � -�
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING ni for ulti-casea wells OR LINER rf a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNEss MATERIAL
ft, ft in.
Company Name
16.INNER CASTING OR TUBING 'eothermal closed-too ,
2.Well Construction Permit#: FROM TO I DIAMETER TffiCIOVESS rIAATrMAL
List all applicable well construction permits(r e,i11C,County,State,Yarlance,eta) .F M ? 18 It. j S in. I 8 6e.1 v
3.Well Use(check well use): ft.. in..
Water Supply Well: 17.5CRE EN
PP Y FROM TO DIAMETER SLAT SIZE THICfOYESS MATERIAL
O.Agricultural ❑M/unicipai/Public ft. ft,
❑Geotherm ti�.e
al(Heating/Cooling Supply) sidential Water Supply(single) , ft. in. <^
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation OWelis>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft, 3 ft 146PG VC-A 3a
❑Monitoring ❑Recovery 3 it 'o fL �
Injection Well: R. FL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Rif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMFLACEMENTMETHODft fL
'•'•
OAquiferTest ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control ft ft G
❑Geothermal(Closed Loop) OTraoer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retu n) ❑Other(explain under##21 Remarks) FRoM To DEsccRBTlox error,tti r�eu sovrork sae etc
�(,� n 0 210 Solt �.
4.Date Well(s)Completed: S Icy Well IDA" a 1 O ft 1403 it G ran.le
ft ft
5a.Well Location: Phone # JSC> ?1/-
ft it .
0- Ida r6 a h (�'
Facility) er Name Fac�y ID#Cif applicable) ft ft
C ft, ft
/8 7 ® L / �G
Physical Address,Cry,and Zip' ft. ft r.
/� > #s_
/ 21.REA ARKS AIR
�101\I xt114
a County Parcel Identification No.(FIR) " y�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: TO
(ifwell field,one lat/longis sufficient) 22.Certification ! ��1✓r-'�"a�1(r�fir) GC ,
, Sign of C ed Well Contractor Date '
6.Is(are)the well(s): permanent or ❑Temporary
By signing thisform,l hereby certify that the well(s)was(were)constructed in vocoiderh with n
7.Is this a repair to an existing well: OYes or 240 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy �4
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under$Zl remarks section or on the back of ihisfornt. 23.Site diagram or additional well details: `�
S.For GeoprobetDPT or Closed--Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction mfn'
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach adddronal pages necessary.:
drilled. 24.SUBIVIarA.L INSTRUCTIONS �.
/003 -(ft)9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following
For multiple weds'lut all,depths if different(example-3@20D I and 2®1001)
i r.
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 •;
ifwater level Is above casing,use
Sit Off: ���s J3b.For In-iection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: .9 (in.) Prggisin,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY .{
�.24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For"Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) a /2- Method of test: Ate,
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
-.. VISITED BY: Q�
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