GW1-2022-08857_Well Construction - GW1_20220912

�plj;^,QgNSI$�U, TIIIDN�R,�CQ ��W-1� For internal Use Only:
1.Well Contractor information:
Gr.��s,� I 0047/wIO ` 14.•WATERZONES h
Well Contractor Name IROOI TO DTSCRrPTIONft. ti�• �yNCWellContractorCertificationNumber TERCASII�TGforaiu]ti-cased wells ORLINER da livableYADKIN WELL COMPANY,INC. ToDIAMETER TffitSQQESS MATERrAL
y ��� �� ,t. 6 ft. 6, AS 16
in.0 an Name )— ERCASINGORTUBING eo2.WellConstructionPermit#: afa��2-2I�� TO DIAMETER TffiCLINFSS 11RATERIAL
List all applicable well construction periods(ca.UIC,County,State,Variance,eta.) ft ft iu.
3.Well Use(checkwell use): ft ft. in.
Water Supply Well: 17.5CRE1 N]FROM TO DIAMETER SLOT SIZE I THICIOYESS I MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 06idential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) g GIWUT
❑Irrigation ❑Wells>100,000 GPD TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery D ft. tf".Ar f• I;n �wL
Injection Well: M ft.
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK Cif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
0Aqu0:r,Test ❑StormwaterDrainage ft ft
❑Expefrmental Technology ❑Subsidence Control ft p ' C
,4rlaa
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DES
❑Geothermal(Iieating/Cooling Return) ❑Other(explain under#21 Remarks) CRIPTION color,hardaess sasvr°ek a size,ctt
��0��������}}.. j Q1 ft it Sip at acJ �t -rr
4.Date well(s)'"Completedc 4-4— `C' veu ID# �'/ - 5Q= it L► it `d•-ma��C •�G �rri
5a.Well Location: Phoneft fL
` ft. /G a R
Facility/Owner e f y1 Facility�ID9 fif%ilaable) !,1 ft. ��/�ft 11` tt f f
l-6 ft ft
Physical Address,City,and Zip ft ft
ae
21.REMARKS r'
burr
Corm Parcel ldentifificaEou No.(MD SEP i 2@22
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 2. ertification: ItN�i ra�:u � 'i.^�n3< ."� iJRi!
-](� ® 24e '/I q N 9d" 21.. 45 mod W 4."ffh
6.Is(are)the well(s): ERleormanent or ❑Temporary afore of Certified Well Coatracror Date
y signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
I5ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
7.Is this a repair to an e�dating well: ❑Yes or o Ot
if this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: �
You may use the back of this page to provide additional well construction info
8.For Geo,o only
1 or s n Closed-Loop I Geothermal Wells having the same (add'See Over'm Remuics Box).You may also attach additional pages if necessary.
construction,only 1 G1�-1 is needed. Indicate TOTAL NUMBER of wells �
drilled: ` ^^ 24.SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: P (t) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(o)20D'and 2®700D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: I Sv (ft) Information Processing UA 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use
r Bit Off' D. 24b•For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
11:Borehole diameter: (m•) 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,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
k(e
. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) v Method of test:
70°I HTH OZ DATE SITE VISITED:_
13b.Disinfection type: ° Amount:
VISITED BY:
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