GW1-2022-09489_Well Construction - GW1_20221014

A.Well n actor In36rrtnfion: --
-� Al L• Gtt/L 14.WATER?ONES
Well Contractor Name FROA4 TO DESCRIPTION
— ��� ft
l ft.
ft. ft
NC Well Contractor Certification Number is,OUTER CASING for multi-rased wells ORLINER if a Gcable
YADKIN WELL COMPANY,INO. KneqERCASING
DIAMETER TEICKNESs MATERIAL
in.
Company Name `}y UBING eothermal dosed-too2.WellCOnst1uctionPermit#: CO //� DrAM sTTER TfficList all applicable well construction permits ax.LUC,County,SRrte,Yariance,eta) in•3.Well Ilse(check well use): in•
17.SCREEN
Water Supply Well: FROM TO p ETER IAM SLOT SUETHICIMSS MATERIAL
❑Agricultural ❑Municipal/Public it. ft• in.
❑Geothermal(Heating/Cooling Supply) Anrlsidential Water Supply(single) it. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD - FROM I TO MATERIAL EMPLACEMENT NMTHOD&AMOUNT
Non Water 6upplyWell: 0 ft ft. a �- lv�dips
❑Monitoring [7Recavery it ft. to O �!r►rs
Injection Well- ft, ft
❑Aquifer Recharge ❑GroundwaterRemediation
19.SAND/GRAVEL,PACK rf a limble
ElAquifer Storage and Recovery 05aliuityBanier Mom I TO MATERIAL LrMPI CEA�NTIPIETHOD
OAquifer Test ❑Stnrmwater Drainage ft ft. nCIT X 9
❑Bxperimental Technology - tiSubsidenee Control ft it
OGeotheimal(Closed Loop) ❑Tracer 20.DRILLTNGLOG attach additional sb€etslfnecessd i•::'j tJf ii
FROM TO DESCRIPTION co iktypr, in sae,ctr-
❑Geothermal(Heating/CoolingRetum`),, ❑Other(explain under#F221JRemadm) O ft- �p � S� 1
4.Date Well(s)Completed: O'er WeIIID# 1 ft °a 04 IL A2 fl 41, so f /ov 3
fL
5R.Well Location: Phone#.31;-�ZZ--ff�G Qr ' •� Ins' _
.ft B`� ff. ��t 01�
Fa 'tycr7i /OwnerName Facility]D#(ifapplicable) r�d ft '4� �61�+ '4 ���[ ��
Ph ft
Physical Address,City,and.Zip ft. ft.
21.REMARKS
County Parcel Idcntification No.ON)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification.
6.Is(are)the well(s): ermanen Signature of Certified Well Contractor Date
t or ❑Temporary ' .,
11y signing thisform,I hereby certify that the walls)was(Were)constructed in accordmce with
7.Is this a repair to an existing well ❑Yes .or 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and That a copy' i
Tf this is a repalr,fdl out known well construction information and espla n The nature of the of this recoid,h beer provided to the well owner.
repair under 921 remarks section or on the back of thisform, 23.Site diagram or additional Well details:
You may use the back of this page to provide additional well construction info
8—For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add See Over'in Remarlm Box).You may also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) Submit this GW-1 within 30 days of well completion per the following: �
For multiple wells list all depths ifdifferent(eromple-3@200'a d 2(a)100D
% 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 (ft•) lnfonnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Tf water level is above easing rose"+" / P
Il.Borehole diameter: (�_(in.) Bit Off: �st 0�O 24b•For Injection Wells: Copy to DWR,Underground Injection Control(lUC)
Program,1636 MSC,Raleigb,NC 27699-1636 ,
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return wells:_Copy to the
(Le.auger.rotary,cable,direct push,etc.) county environmental health deparhnent of the county where installed
Pe FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: 44n.
DATE SITE VISITED: (g
13b.Disinfection type: 70/0o HTH Amount:
0?'
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