GW1-2022-08606_Well Construction - GW1_20220411

WELL ComMi RUC 1TION RECORD QW-1) For Internal Use Only:
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I.Well Contractor Informntion: # #'
,A , I r
20' Iv MU l l t� 14.WATER ZONES f
Well Contac Name *' °it 1 V-j-:! FROM TO ' P DESCtu ON
k. ft. 6. /f�� Yin 1
APR 11 202? �s 7 7 J ,
NC Well Contractor Certification Number
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15.OUTER CASING foraiulti=resedwells ORLWER da
YADKIN WELL COMPANY,INC. a,�l r, 1 FROM TO DTAMETER' TffiCICNESS MATERTAI. pep'�t
Co anY Name *;^!i�;;l l c
�. + 16.1NNM CASING OR TUBING eothermal dosed 160• 'T
2.Well Construction Permit#: 33 CID FROM TO DIAAM? R I THICKNESS hIATIOLIAT: k '
List all applicable well construction pem ils(i e 17IC,County,Stale,Variance,etc.J 7� ft t/ in. SJ 3 PJG `� F
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3.Well Use(check well use): ft ft'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS. .MATERIAL.-='t
❑Agricultural ❑Municipal/Public it, ft, in
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. rd: Y 4
vl.
❑Indush-ial/Corrunmial ❑Residential Water Supply(shared) 16.GROUT `` 1: r1 t '•:
❑Irrigation ❑Wells>100,000 GPD KFR�OM �TpO, MATERIAL` EMPLACEMENTMETHOWWAMOUNTallonWater Supply Well: `3 fL -e-,-,Ck! U V.rCG❑Monitorin ❑Recov ftInjection Well: fL
�"❑Aquifer Recharge ❑Groundwater Remediation
. RAVELPACK Ofa livable p �¢ ,. s 1 •.
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 5-LAERNE+NTMEM57RXfL
i x
❑StawarDaage❑Aquifer Test X11 ,
❑Experimental Technology ❑Subsidence Central ft. it. ;* 32
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa`• 1@ ar gl r
FROM TO' DESCRIMON color,hardnevs'ioiVinek
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks)
„�Z� ,tam•. i � ;
4.Date Wells Com leted:3 4-1—Well]M r`!c," 's. & 7 R ,P J� n� i�� ZfL "
Phone # o � -.
5a.Well Location: a- ft. �� !���a ��ac 'S•.
fti a6y'fL /) ��d �rc
Facility/Owner Name Fadility M#(if applicable) ft ftft
2�7d uz�• �=ace t � r�ra�t ,> s;'
Physical address,CdY,and tb ft. ta
ecQ 21.REMARKS
County Parcel Nautification No.(PJrl) x 5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification.,
3 3 o SYN 'Ss 6 �t`3 ���, o Z. w
6.Is(are)the well(s): kermanent or ❑Temporary Si a of CertififidWell Contactor Date s,
r
Via•,
By signingthisform Thereby ceo that theivell(s)was(were);constructeil in
accotdrmce with
7.Is this a repair to an existing well: ❑Yes or To ,- '
I SA NCAC OZC.Ol OD or/SA NCAC OZC.0200 Well Constriictlon Standards and that a copy
If this is a repair,A out known well construction brfarmation and explain the nature of the of this record has been providid to the well owner l+ ITM:
repair under#21 remarks section or on the back of this form.
23.Site diagram or additionalwell r
details. `€
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of Us page to provide additional we"'conshvchon
construction,only 1 GW-1 i�needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach addRronal pages tf necessary.
drilled: r 24.SUBMITTAL INSTRUCTIONS +
�l02- (ft.) ;w
9.Total well depth below land surface: Submit this GW-1 within 30 days ewell completion per the following: ,
For multiple wells list all depths lfdlfferent(example-3@200'and 2Q100�
O 24a. For All Wells: Original forrn to Division of Water•Resources�(DWR), '
10.Static water level below top of casing: .s (ft•) Information Processing Unit,1617'MSC Raleigh,NC 27699-1611 #
Ifwaterlevel is above casing,use
Bit Off: J J 24b.For Injection Wells:Copy to,DWR,-Underground Injection Contml(IUC) .
11,Borehole diameter: (m) Program,1636 MSC,Raleigh,NC�27699-1636 "y '
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return wells.Copyto the '
(Lt.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'"'
.1 Permit Program,1611 MSC Raleigh,NC 27699-1611,,;. 's
13a.Yield(gpm) / Method oftest: �e�V
DATE S
q OZ I E VIS TED: '.YG`a� e,
13b.Disinfection type: 70%HTH Amount: f R � �r A
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VISITED BY: 1wL