GW1-2022-08619_Well Construction - GW1_20220513

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'-i V 6QN, IRU, �N��C��➢��P��-�� For Internal Use Only:
1 Wdl Contractor lnformatton wts
�ff 14.WATER ZONES M
I FROM I TO I DESCRIPTION
s
Well Conhac XNW-724
'f€ : / 5ft. 0t-' It. ft
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� NC We1I,Conhactus CetitficalsoaNumba� �°t 15.OUTER CASING for mu)fi-rased vra➢s ORLINER'�f a licahle
i FROM TO DIAMETER THICKNESS ' MATERIAL
1 YADKINWELLCOMPANY,sINC ft. in.
$ /
CompanyName� Via/ 16.INNER CASING ORTUBING eothermalclosed-loo :.
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Et 2 i1ei nBtClletJOn�ermit � LJ FROM TO Dis*T� R TffiCICNE55:; TATERIAL
�x ..• ft /` ft I sin. s��z�t'. (�&,C,
List all applicable well cronrtruction pet its(Le UIC,County,Slate,i�ariance,etc) 7 V l j- 1
3We1HUse(checkmuse):,
ft ft. in.
17.SCREEN
Water Supply W Ill mom TO DIAMETER sLOT slzE THICIOYESs MATERIAL
OAgricultaral , € OMunicipaUPublic ft. ft. in.
t
E pGeothennal(Iieetin�,Cooling Supply) t:sidential Water Supply(single) ft ft. in.
�Indu lal/Commerc sidential Water Supply(shared) 1s.GROUT
p rtw*" Wells>IOD,000 GPD FROM TO MATEIUAI EMPLACEMENT METHOD&AMOUNT
i
Non K!at"erSupplyWell
olvionimria91 I7Recovery it 3) .,_sJ�•• J •�
Injection WeIL• ft ft
Groundwater Remediation
pAglltferRetharge 19.SANDIGRAVELPACK da licable)
yuifcr Storage andtRecovery ❑Salinity Barrier FROM TO MATERIAL EMPIACEMENTMETHOD
r. s
,s 1�AquiferTest 1" L1Sttirmwater Drainage
OExperimelltal Technolggy OSubsidence Control ft it
sti: �Geothemlal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets ifnecessaryl
FROM To, DESCRIPTION miar,hardness,solYroe& 'n sce,eta
OGe_othermal(Heating/CyoolipgtRehun) oOther(explain under#21 Remarks)
( p o ft �y• .
4.Date Wells)Completed: J�`�' '< Well ID ft ��d �v.e ,
Sa�4'ell Loeationc 1. Ox @ # a a'
P h .n •� Q Tj ft $1 $ ��..587�
ti.a 1 ti YET`d ilA� �b
r a ? Facility iD#(if applicable) ft ft
Faaihty/: erN e
ft ft
Physieel Aathtes,c;ty,�a.zip ' '��� C JC. ft ft.
J LULL
Parcel Identification No.(PIIJ) C
mot ,g ion Procw�irlg Und
5b.Lat<tude and+longitude in degrees/minutes/seconds or decimal degrees: 1,
(ifwellsfieitl,one let/long-iciest) 22.Certification:
1 .
5i re of C ed Well Contactor. D�
thetwell(s):, ,er,•manent or "OTemporary
y x By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
t 7 Is,t a repair D IM aristing welt oYes or o 15A NCAC 02C.0100 of I5A NCAC 02C.0200 Pell Construction Standards and that a copy
` fTvtown well canshvctton Triformation d erplain the nature of the of this retard has been provided to the well owner.
t If ihis,is a gg,,frl ��to f
s tea..
repatrimder#27l'remarks.se taaoronthc ack this form. 23.Site diagram or additionalwell details:
h
8'ForGeoprobe/DPT or Qosed Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
k c_onsiruction,only 1, W 1 is needed lndtcate TOTAL MUMMER of wells
(add See Over'in Remarks Box).You may also attach additional pages if necessary.
I dulled:, r 24.SUBMITTAL INSTRUCTIONS s
9Tota1 well de th below:land,surface: t �a� (�)
P Submit this GW-1 within 30 days of well completion per the following: Q
FormulhplewelJs,lisf.allydepths;ifdj�erent(ecataple-3(a�0 'and2®100) `
24a. For All Wells: Original;form to Division of Water Resources (DWR),
10°Static water level`below;top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwoterlevells'�abovecasingrvse /
rt In.
Sit Off: 6•o90 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Ile,Bore�ho] ameter.: C ) Program,1636 MSC,Raleigh,NC'27699-1636
ROTARY
12.Vyeli eonstructlon-method:. a 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
s "
e` push„ ) county environmental health department of the county where installed
(ta auger rotary cable*dae
FOR WATER STJPPLY PVET�IiS ONLY: 24d.For Water Wells Producing over 100,000 GPD:Copy to DWR,CCPCUA
f e Permit Program,1611 MSC,Raleigh,NC 27699-1611
13arYield(gpm) �rNlethod oftest: �. 1
. . ' w ,� tlA7F SITE VISITED•