GW1-2022-09475_Well Construction - GW1_20221014

9
,,X'rSZL CONSTRUCTION;TIC N-RECORD(GW-1) For Internal Use Only: ;
1.Well Contractor lnformadon,
r�U S L 1 J l yYflirt� i 14.WATER ZONES p
Well Contractor Nam FROM To DESCRIPTION
-3 c> �e/ � �S ft,
0 it. 5 it.
NC Well Contractor Certification Number
15,OUTER CASING for multi-cased wells ORLINER if a Gcable
YADKIN WELL COMPANY,INC. FROM To DUMETEER TH Crfl S1 MATERIAL
CompanyName��t�� �S�'�7 ie.�d'�7'®'� ft. 6,W!5 in' S//Q'O'� U C
16.INNER CAKING OR TUBING 'eothermal dosed loo }
2.Well Construction Permit#: �.�� FROM To Drawn-mA TE[1!1&rss I MATMIAL
List all applicable well constructlon permits ri e.InG County,Slate,Variance,eta) fL it in. p
3.Well Use(checkwell use): ft, it in. 4
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TEaOC LESS MATERIAL
❑Agricultural ❑M impaM. blic ft. ft. 16. '
❑Geothermal(Heating/Cooling Supply) gAsideritial Water Supply(single) ft, ft. in.
❑IndustriaVCommercial oResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Welis>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. /� ft. �tss�tM, ( ,(t : lat �
❑Monitoring ❑Recovery it ft.
Injection Well: -
ft. ft -.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK da llrable
❑AquifCr Storage andRecovert' ❑5alhaity Barrier
FROM TO MATERIAL ERffLACEMENTM=, OD
❑Aquifer Test ❑StormwaterDrainage ft it
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional slfeetsifnecessa
FROM. TO DESCRIPTION color,hardness,solYroek c sue,cte.
❑Geothermal,(Heating/CooIingRetmn) ❑Other(explain
qunder
�#ry21 Remarks) ft fL Ste , o sd�7
4.Date WeU(s)Completedg!a 00WeUID#/"� A �•� G y' ft,' ft' �U)K I_b014, Se
4. ft
5a.Well Location: Phone#SJC,,. .301166G 9
ft 14 ft
Faoility/OwnerName J yp.FadlliittyyID#(ifapplicable) tpVL % yg ft �Q -,.:tt e
U''� m`-'i.' d ft it 'f':. _ ,''- y "�pg
//JJ ( au
l 13 13 P,
Physical Address,City,and Zip
ft fL 3
k li.
/ es 21.RAMARICR
County ParcelIdentifoationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwoll field,one lathongis sufficient) 22.Certificatio
6.Is(are)the well(s): [permanent or ❑Temporary
Sign edified Well Contractor bate
�� ing thisform,I hereby ceritfy that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or �41 15A NCAC 02C.0100 or ISA NCAC O2C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out larown well construction information and explain the nature of the of this record has been provided to the well owner.
repair"under 421 remarlasection or on the back ofthisform.
_ 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 mfe
construction,only 1 GW-1 i�needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d` (ft)
For multiple wells list all depths trdiffereni(example-3@200'and 2®100D Submit this GPV-1 within 30 days of well completion per the following:
i
24a. For All Wells: original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 LOP (ft) Information Processing Unit 1617�MSC,Raleigh,NC 27699-1617 '
Ifwater level is above casing use
11.Borehole diameter (in.) Bit Off: (®s 0�� 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(TUC)
Pragrarn,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Opefi-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
13a..Yield(gpm) � Method of test: Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13b.Disinfection type: 7D%HTH Amount: OZ DATE SITE VISITED:
---- - VISITED BY: