GW1-2022-08568_Well Construction - GW1_20220513

I.WPJI Contractor lnformntion r
1114AWAPER?2ONES
T "'tFROM ;TOE&DESCRIPTION
WeII Conhaotor Name Vi
y« .kho
NC Well Contractor Ce[hlieahoatNumber , *1SM TIHR(CA`S XG fo's"mn7fi-rased wells IOR�T;II!IERT da licablb
JIFROMMM STO 165IAMSPFR �THICi�T&SS MATERTAL
YADKIN WELL COMPANY;INC. � � ��V � �
comp y
�161Il�WER(CASING OR4TIRINGr"" tbtrmal�rliued=loo`
�' •FRUaia/l RO 1111
j �Di� Qnt 14TffiCIQVT;96 �MATffitIAL
2.Well Construction Perm
P }(tee ��
Ltst all appllaable>well cortstru�fon erimtI�kUIC;�Coun She i<arlanea,a 4tc f VI�tl ` r
3.Well Use(chick well use)
i ti-- ."• sr�t 627ISCREEN
Water$np'ply Wellc �` +*FROM M STUtt IIDLO TERIrNO
lal or;slzsrll�T�G7QYILSSIr�IrinrExli�I.
( ❑Agncultiral ®Municipal/publio ft. ft.
i OGeothenml,(Heatmg/Cooliag Supply) residential Water Supply(single) ft in.
4�SYRS
Olndustr►al/CommectalrT- . �Residentisl Water Supply(shared) laiBTGROUT
®Wells>100 000 GPl) 1#FROMi1n YTOt IMATERIAL�LMEPlPLICEMENT1METaoDT✓ A1ISOONT
{
i Non-Rater Supply Well
at
Monitoring
g r
Injection Well: I
urfer Ucharge;
❑Aq ` ¢ [7G oundweter,Remediation i
,3 S 11915ANVIGBANEOPACKi d,a licalill
❑Agwfer Storage and Recoveryk ❑Salinity Barrier VFROMI frTOtl I1MiATERIAL lE11�LCC. tiTrMSfSOD
❑A`wfrsTest µ' F' OStnrmwaterDrainage �i
q
O]?xper>meutal Tech' ygy Subsidence Coalrol 1
I i7`Geothermal(ClosedLoop) pltracer s20)DREI:DVGIOG►attaehTsdaltional h ts'ifnecnso
MTO»1DHSCR=ON;mloilLacdaeuTioNroeY'. T
C OGeothff01(Heating1Co6lin7g:Rehun) []0_ther,(gxplain under,#Zl
.7v
4 Datewellj( ComHIREM:, 411E 1�1 Weu _� at -''�► 3 'S _ r►�
5a.Well ilae tion:, Phone # 3t3�' � l_
Facaty/0IL
{ Name Faci]ity II)It(if applicable)
'Physical A s tidy,andMN
Zip
4a.,;� fi IFiL�is$IisABlts i ny.,rsl;'_-^'.
C-6 Pmcelrldentc6catioallo.(FIId)
56-Latitude and:longitnde in degreeshminuteslSeeonds or decimal degrees:
(if
wellMCI d,:onelat/loagis,sufficient) 22.Certifieation:.
,� , sib•"'�"�c-' Bdw61110 0a>r Hate
6 Is{are)the"Well(s) ermanent or OTemporary
°`"�` -. :y �: �h'T By;rtgn-m4g,>�tsform,l herby ce�ijfy at the ell(s)was(were) in axa
7 Is thts a rep gm an ensttng well: or I I, o � ��:�` ISA)NG4C 02C 0700 oc 13A�NCAC 01C.0200 fPell Con etfon Stm�do d a
,Ifthrs u rPp%;ft or I Fn conshvctton tmalian q�id.�plain th " ituseo die � trreaord has bem provfded o the ( er
aysardertl2l:remorks�fon,o>�eb'�ae�kofthisform.
� 7GP -�. �e:rr. 23.Site diagram ar addltionalwell details:
8 For Geoprobe/DPT or Closed--Loop Geothermal Wells having thasame You may use the back of this page provide tionsl
conshrutction,only 1 G. 1 isaeeded. In'dici OTALI�TiJMBBR of wells (add'See Over'in Rzmarls Hax).You may also etiach arlddlo lf«
-,
l . dniledA�;� � i 7�1.SUBNIITPALINSTRUCTiUN3
7, 3 yz
9 Total`well depth,belaw land surface: ( ') Submit thin GW-1 within 30 days ofwell comple pe a fo
For multiple wells�Hst a l4depfhsfdlff mpte�3Ua 200'm d 2�1.00�
t ,� (ft.) a---or All Wells: Original folm o Division o a a
10 Statiewaterlevel below top of casing Information ptocessingUnit,1617MSC,Raleagh,NC 7699- lt7 i
L ifw ertiev,, 1rJa6ove eaF!Pn 9F��ics4e +"
e;t off; 5 9y� 2Ab.For Injection W..ells:Copy to WR,Underground Inj 'on � n
11.Borehole diameters f i). P,rogram,l'636 hiISC,Raleigh,NC�2Z69 -1636
12.Well constrncttori method"kA�R ROTARY . 4c. ,or Water 5u 1,and 0 - o Geotherm a rn op
(Le.suge,rotary,cable,duect pnsb;etc)'" K =4 ty envson`me`ntalb6fath dap—tffent df the county where installed
FOR WATER SUPPLY WELLS ONLY n ' h Walla rodMin aver 10D 000 GPD:Copy to D k-
` r t,^ P itOb—O am, 61i1
13s.Yield(apm) 30L Methyod oftest: r
70%HTH 'gla y � OZ DATE SITE VISITED:
13b.Disinfection type: a Amount•.
VISITED BY: w Oti '
Sri ral