GW1-2022-08900_Well Construction - GW1_20220912

5Lk c-oNS'TiMUC 1T10N RECORD (;G'V-V-1) For Internal Use Only:
e —e
1.Well Contractor Inforrontion:
/41 A 0 km 14,WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
3 o 3�L} a loll t V- ft.
ft, ft D
NC Well Contractor Certification Number ID
is.OUTER CASING r multi cased webs ORL Gcable
YADKIN WELL COMPANY,INC. FROM DIAMEETER 5 MATERIAL
ft.
Company Name d oo.,mi3 e— Ci t Q 2-Vs-- GCD YO
16.INNER CASING OR TUBING(geothermal closed-loop)
`Tye ® FROM TO DIAMETER TTBCE1VE55 T4ATERIAL
2.Well Construction Permit#: -�
List all applicable well construction peen fls(i e.UIC,County,Slate,Variance etc) R /� ft in. j/ Oak,;
3.Well Use(ebeckwtil use): Y. fL ev ft.
in- p�/
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TffiCIQYESS MATERIAL
DAgricultural ❑M�:unicipaLTnblic' ft. in.
❑Geothermal(Hesting/Cooling Supply) g esidential Water Supply(single)
❑Industdal/Commercial ❑Residential Water Supply(shared) g•GROUT
❑Imgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. ft. (?V,o�;
❑Monitoring ❑Recovery tt 3o ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROMD/GI TO— PACK MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothemial(Closed Loop) ❑Tracer 20.DRILUNG LOG attachadditional sheets ifnecessary)
❑Geothermal(Heating/Cooling Rehm) ❑Other,(explain Under01 Remarks) FROM TO DESCRIPTION color,hardness,soilfrork size,etc
ft. 3 I'. So,e/
4.Date Wel(s)Completed: Well ID# ArAD �( r Jo K ; m Cy r
5a,WellLocation: Phone #q(q-qZ2. 2 1"2-C fL ft
ft ft
Fmlfty/OwncrNaml Facility ID#(ffapplicable) ft ft
1w��,�. �v�� Rd C�.�r�(�,l�il ft. ft
° FY '
Phy
sical Address,Crtr.and Zip C3Qf G y t��
21.RNMARTCA u v L —
County Parcel Identification No.anN)
Into
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JkV
(if well field,one lat/longiss sufficient) 22.Certification:
6.Is(are)the well(s): 113Permanent or ❑Temporary Signature of Certified Well Coimactor Date
By signing thlsform I hereby certify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &<0 15ANC4C 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a ropy
,phis it a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarkr section or on the back of thisfonn.
23.Site diagram or additional well 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 GW is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24,SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: w (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ffeVerent(example-3@200'and 2®100�
3O ft 24a. For All Wells: Original!fora to Division of Water Resources (DWR),
f Static water level below top of casing:
If ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 Q
water level Ir above casing,use"+"
Il.Borehole diameter (in.) Bit Off' �� 1 D S 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY I
24c.For Water Supply and Open-Loop Geothermal'Relvrn 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 produ I a over 100,000 GPD:Copy to DWR,CCPCUA
e Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) o�� Method of test: PI �
13b.Disinfection type: 70%HTH .Amount: Z OZ DATE SITE VISITED: r
VISITED BY:
-Pri t'P_ — ,