GW1-2022-07573_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I m
1.Well Contractor In-forogtion:
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CO W n 14.WATER 201YE5 I
Well Contractor Name FROM TO SCRIPTION
11 /� G oft. Z fr. DEi
56 16 A b Qs-R' m ft i/
NC Well Contractor Certification Number 1S.OUTER CASING for multi-rased wells ORLIN if a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER SS MATERIAL
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Company Name q c a 16.INNER CASING OR TUBING feeothering closed-loon)
2.Well ConstructionPermit#: FROM To DIAMLrM I TMC0MS AIATMUAL
List all applicable well construction permits(Ie.UIC,County,State,Variance,eta) tl ft [,r'�' in. /L e G tl /_�/✓ S4�1
3.Well Use(checkwell use): ft. ft. l� in. V 00 t/ / /
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT StrE TSICIMSS MA
❑Agricultural ❑MunicipaYPublic ft. g, in.
❑Geotbermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. .00
❑Industrial/Commercial residential Water Supply(shared) 18.GROUT
❑Irrigation i❑Wells>100,000 GPD FROM TO MTERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ' S- f Alt.,4 Cp.,ft E Arcssure,
❑Monitoring ❑Recovery ft %
Injection Well: tt
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVEL PACK da Ucable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. Ei IACEMENTAtETIIOD
❑Aquifer Test ❑Stormwater Drainage ft R
❑Experimental Technology ❑Subsidence Control it.
❑Geothermal(Closed Loop) oTracer .DRILLING LOG f2ttach additional sheets if necessary)
❑Geothermal(Heating/Cooling Rdurn) ❑Other(explain under#21 Remada) FROM To nESCRI1111ON color,Mess,soiuroek ibm etc
4.Date Wells)Completed:'?—dl-U well nv X R' loosefi 4
5a.Well Location: Phoneft fL
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Fac�lri ty OwnerName I'-Miiy]D#(if applicable) fL = a
ft fL
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Physical A/ddmsfs-,City.and Zip p IJ 3 1
21.REMARKS ..(-}-�
11n��t'4i: ;4�
County Parcel Identification No.MN) r jQiBo-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3 _y6�o N 5t1 3j' 3-2e4 6-
w 7 01/-22
6.Is(are)the well(s):Aermanent or ❑Temporary Tigirature of Certified Well Contractor Date
By stgning thisform,I hereby certify that the well(s)was(x ere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )"o ISA NCAC 02C.0100 or lM NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of ibis record has beenprovided to the well owner.
repafrvnder121 remorkrseetionoran the back afthisform.
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 need dieate TOTAL NUMBER of wells (add See Over'in Remains Box).You may also attach additional pages if necessary.
drilled: L 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /U o g (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdffferm1(example-3@200'and Z l001
10.Static water level below top of casing: /*0
(ft)
24a' For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" /► Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 °
11 Borehole diameter: (in.) Bit Off: (9 0 097 74b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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,etc.) 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) 02 /L Method of test: Vk-
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13b.Disinfection type: 70%HTH Amount: 4L OZ DATE SITE VISITED:
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VISITED BY: f�