GW1-2022-09481_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD d'GW-1) For Internal Use Only:
I.Well Contractor Informntion: 11 ''�
3er!'( (A3la`t ins 14.WATER TONES
Well ContrecmrName
FROM I7'O DFSCRrPT10N
atisa A IL (bo ft
R 1 2Gp R ,y
NC Well Coninemr CetiScationNumber 6.OUTER CAMM&r suolti-rased wells)ORLINER der EcaWe
YADKIN WELL COMPANY,INC. FROM TO DMMURR THICRNasS MATERIAL
I. Ft R n.
Company Nome e, '-I 6.INNER CASIIiG OH TUBING thermal closed-loop)
2.Well Construction Permit#: 3154ci I PROM To Dw>areR ' Ocg esa MATMUAL
Lon all applicable well camlruetion permits(La.UIC,County,State,Yorlonce,etc) }' ft R G I`, ia. lJ�a I per
3.Well Use(check well use): R R
Water Supply Well: 17.SCREEN
FROM TO DIAMEIFA SLOT SZE THICKNICSa MATERUL
OAp�iculnuel OMunicipaWublic ft. To
in.
DGeothermal(Heating/Cooling Supply) 26Sidential Water Supply(single)
R R in.
DlndustriallCoaunercial []Residential Water Supply(shared) IS.GROUT
chrigation OWells>100000 OFD FROM I m MATEIDAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply well: O ft. ay ti' 1 F(dle Po vred lei S
[]Monitoring []Recovery R R 5
Injection Well:
R R
[]Aquifer Recharge []Groundwater Remedistion
DAgmfer Storage and Recovery OSalmdy Barrier mom/G11MVEL PACE a xmiAcEMe.NTsirmon
[]Aquifer Test OStormwater Drainage R R
[]Experimental Technology []Subsidence Control fL ft.
[]Geothermal(Closed Loop) OTraocr 20.DRILLING LOG h ch additional sheets if necessary)
OGeuthermal(Heating/Cooling Rd=) []Other(explain under 421 Remedrs) FRoxi zo DuC3WM0N .iormsm rwlmrrr sic eau
n D R 38 R Sot'
4.Date Well(s)Completed: 7 L0 -1 weu mn fl+?"2�(,Wo 38 IL y�3 IL
5s.WeuLDeation: Phone # AFAR by `
tYlnrzr L Qf�tGr' Q2E-7?3-S13� R R
Fem7itylOwn¢ a PecilityIDM(dapplioable) R R OC T
Sa fe 54oele b r. M&k A)z- f` it
Pbysical Address.Glty,and Zip R fL
Asime z1 aEI1fAHRB
CDU* Paul Idmbficalion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,ono lat/longis sufficient) 22.Certification:
?(A Uo`13(0 N — ' S783.44 w
� 4.A,r, (.�c 9 {'(a �2
6.1s(are)the well(&): LdPermaneut or DTemporary Sipalure ofC ed well Contractor Data
�� By signing thitform,I hemby Geri fy that the wells)was(were)cwrslrvcied in accordance with
7.Is this a repair to an existing well: []Yes or LRN, 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
Ifthis it a repair,fill oat!mown well construction L7(ormation mid explain the nature ofthe oflhis recordhas been provided to the well owner.
repair under I21 remark section or on the back ofthitform.
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-1 is needed. Indicate TOTALNUMBBR of wells (add'See Over'in Remade Box).You may also attach additional pages ifnecessary.
dulled' ( 24.SUBN=AL INSTRUCTIONS
9.Total well depth below land surface: W 4D A) Submit this GW-1 within 30 days dwell completion per the following:
Far multiple wells list all depths/fdif(eml(example-3@200'and2®1001
10.Static water level below top of casing: (,O (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwwer level Is above casing,we"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
r 11.Borehole diameter: (In.)
Bit Off: G ad� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
I.
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the i
(La.auger,rotary,cable,direct Peak am.) county environmental health department of the county where installed
!
FOR WATER SUPPLY WELLS ONLY: 24d.For Water W ells roducin over 100 000 GPD:Co D Copy to WR,CCPCUA t.
Peanut Program, 11 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) , Method of test: A 1i- D G
13b.Disinfection type: 70%NTN Amount: ) 02 DATE SITE VISITED: J
VISITED BY: