GW1-2022-07588_Well Construction - GW1_20220815

WELL L CONSTRUCTION RECORD(GW-I c For Internal Use Only;
1.Well Contractor Information:
Jecc w L ai�(A S 14.WATER ZONES k
Well Contractor Name FROM TO I DESCRIPTION
�)ysaA 70 ft' 2 ft. .71��,
ft. ft
NC Well Contractor Certification Number 15,OUTER CASING for multi-rased yells ORLINER rf a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCSNESs MATERIAL
ft. ft. in.
Company Name
015
� ` '�/� 16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: O l 5 16-3—t�61a FROM TO DIAMETER THICI(NIMS I MATERIAL
LW all applicable well construction permits(i e.UIC,County,State,Variance,eta.) + � fl- �j i'y ia,
3.Well Use(check well use): • ft' ft' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mimicipal/Public ft. ft. in.
dGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT AM,THOD&AMOUNT
Non-Water Supply Well: O ft' ft &k QW m crJ 3 4 9
❑Monitoring ❑Recovery ft ft mule(e GCov �v o+
Injection Well: ft. R
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK sir IIcable
❑ATiif Stdrage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EAVLACEMENT METHOD C
❑Aquifer Test ❑Stormwater Drainage ft it
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(lieating/Cooling Ret[un) ❑Other(explain unde�r#21 Remarks) Q ft- S3 ILe O FROM TO DESCRIPTION color,hardness,soiVroek .'e she,etc
t-1
4.Date Well(s)Completed: to .Dg Z2 Well ID# I Q- ' S3 ft 4;Qft J `V
5a.Well Location: ft ft r? r s `�'
Phone # '�lP- �-
ft ft.
F vmerNeme Facility M#(if applicable) ft ft 1 —
I �1 1
t1 1(� ft. fL � », i�Und
rlQ U YL�A U► �� 4
Physical Address,CSiy,and Zip ft R
y��a 21.REMARKS 0
Carty /�//1� Parcel Ideal fication No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilongis sufficient) 22.Certification:
N 9f 3 W G �2
6.Is(are)the well(s): ❑Permanent or ❑Temporary Siguaturi�of Cert(fied Well Contactor Date
By signing thisform,1hereby certify that the well(s)was(were)constructed in accordmmce with
7.Is this a repair to an eusting well: ❑Yes or nNo 15ANCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction LYandards and that a copy
If this Is a repair,fdl out known well construction information and ezplaih the nature of the of this record has been provided to the well owner.
repair corder f21 remarks section or on the back of this form.
23.Site diagram or additionalwell 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 GVp-1 is needed. Intricate TOTAL NUMBER of wells (add See Over'in Remarics Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 v ) (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdifjerent(example-3Q200'and 2®1001
may, 24a. For All Wells: Original jform to Division of Water Resources (DWR),
10.Static water level below top of casing: s V (ft.)
Information Processing Unrt,16I7 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use
Bit Off: O ( 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11 Borehole diameter: L1 (in.) Program,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,eto) county environmental health departrment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droduci a over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2 Method of test: 04K,
Permit Program,1611 MSC,Raleigh,NC 27699-1611
'
13b.Disinfection type: 70%HTH Amount: 1'7 OZ DATE SITE VISITED:
VISITED BY: