GW1-2022-08916_Well Construction - GW1_20220912

� '+CONS IR.UC 1TION RECORD(GW 1) � � '�"� ��I
For Internal Use Only;
I, !Yell Contrac Iformation;
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14.WATER ZONES Y Well Contractor Name FROT4 TO �•pBSCIiIpTION
13
t.
NC Well Contractor Certification Numbs
YADKIN WELL COMPANY,INC. 15.OUTER CASING-for multi-cased wells
PROM TO OR LDVER rf a Gcable
DrAMET�R TMEXCam EsS T4lTER1AL
Company Name fr• ft• i in.
2.Well ConstructionPermit#: 3 16-INNER CASING ORTOBING 'eothermalclosed-loo
List all applicable well construction peFROM TO DIANIETgR THICIfNFS5 T4AIL+RIAL rmits a fIIC County,State,Parlonce eta) l ft R 0 in
�3.Well Use(check well use): � ft•
in.
Water Supply Well: 17.SCREEN
FlAgricultural OMunicipal/Public; FROM TO DIAMETEg SLOT SME CKMS MAT FA V
17Gaoth q'sl(Iieating/CooIing Supply) R R'
. .r�;,.. - PP Y) 'Residential Water Supply(single)
l7Industrial/Cominercial R ft• in:
e1 Water Supply(shared)
I]Irri ation -^'Q'' I&GROUT
-� 4. 00,000 OPI) FROM TO MA L
Non Warner Supply W ,e _ r U ft . EMPLACEMENT T�THOD&AMOUNT•
8.
0Monitoring _ n t L fit.t�t
ery ft
Injection Well: t - (A/` M t `J
OAquifer Rdch a URA ft R
t'T��l*yNdwater Remediation
OAquifer Storage and Re VNQy �t,Barrier 5AND/GRAVEL PACK rin linable)
OAquifer Test FROM TO TSAT sure r EMPLACEIYLEtiT METHOD
❑Stormwater Drainage ft ft
f]Bxperiuiental Technology' OSubsidence Control A
R ft
❑GeetheO7ra1(Closed Loop) :. ' OTraceT sheets if ae
Z0.DRII,LIlVG LOG at[sch additional eessa❑Oeotheimel(Heating/Cooling Betrmm) 00ther(explain under#.21 Remarks) EOM To D&4CRTPTiON eomr,hardnen,snVrock ,.
ft e. Sil-!tC as r
))�� ll s d r�4.bate Well(s)Completed: `0'77`d We11ID#_!�/4 P-! 8 ft 7 f a a
5a.Well Location: Phone #30 r�`88— �, ft 6t�Z ft
f M�
z• `,�
y4 1-/it' - ft &
Facility/OwnerNemeAl
Facilitym#Cif applicable) ft ft
�0 4 /"
Physical Address,City,an J `
it ft.
County Parcel Identification No.(PIIq)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient)
' �� a 22.Certification:
�3U- t'7 N -71 R,
6.Is(are)the we11(s):(Permanent or []Temporary Srgoafnre of Certified
Date ;
7.Is this a repair to an existing Well. OYes or No BY dlgning thisform,I hereby ceri�that the wells)was(were)constructed in accordmnce wtth,
this a [p 15A NCAC 02C.0100 or!SA NCAC OZC:0200 Well Construction Standards and that a copy I
y repo/r,fdl out known well construction information and cuplain the nature ofthe ofihts recordhas beenprovlded[o the well owner.
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional wail details: t
1
B.For Geoprobe/DPT;or Closed-Loop Geothermal Wells haying the same You may use the back of this page to provide additional well construction info
construction,only 1 OW=1 is r eded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).you may also attach additional pages necessary 1
drilled `'
/+D�IL 24.SLBNIlTTAL INSTRUCTIONS'
9.Total well depth below land surface: 6 ( ) ;
For multiple wells list all depths lfdffferent(cramp/e-3to3200'and 1®1001 Submit this GW-1 within 30 days of ivveIl completion per the following:
A.Static water level below top of casing: 24a. For All Wells: Original I (ft) t 1 form to Division of Water Resources (DWR), =.f water level!s above casing,use"+° Information Processing Unit, 617 MSC,Raleigh,NC 27699-1617
ft.Borehole diameter: G Bit Off:s►��,gL
(in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-I636 r
12.Well construction method: j
(ia.auger,rotary,cable,direct push,etc.) G u For Water Supply and Open-Loop,Geothermal Return Welts Copy to the
county environmental health department of the county where installed
FOR WATER'SUPPL WELTS ONLY;
24d.For Water Wells producing over 100 000 GPD Copy to DWR,CCP UA r 13a.Yield(gpm) Method of test: �.1 l/ Permit Prognun,1611 MSC,Raleigh,NC 27699-16I1
13b.Disinfection type: 70%HTH Amount: pl OZ DATE SITE VISITED:
Pri rt-e - vtcrrr n nv.