GW1-2022-10290_Well Construction - GW1_20221114

tee,y y •CONS RIUCTION RECORD(G'V-V-111 For Internal Use Only:
1.Well Contractor Information: IL ^ C
® ' 14.WATER ZONES
TO
Well Contractor N e N O V 1 A 2022 0 0� ft fr DES rION� ^1: 714-
r�
Prt`: ^�asr. Urik ft. ' ft
NC Well Contractor Certification Number Ifhufril:l O. 3Y3 .3y/p
r•.i.ztp,,��G
.° 15.OUTER CASING for m ulti-rase ells ORLINER rf a licable
YADKIN WELL COMPANY,INC. FROM To DL►V=R THIC[OQEss MATERIAL,
ft. ft. in.
i. CompaayName �rif®p 16.INNER CASING OR TUBING eothermal dosed-loop)
Z.Well Construction Permit#:S-V � �t�6a d FROM To DIAMETER THICKNrss MATERIAL
LW all applicable well construction permits(i.e.UIC,Counfy,State,Variance,etc) ` ft 1 � n' ,0 a
3.Well Use(checkwell use): ft ft. rn
17.SCREEN
Water Supply Well: FROM TO DIAMETER sLOTSIZE TmCIMSS MATERIAL
❑Agricultural ❑Munic1pal1Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esldential Water Supply(single) ft it in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENTr%MTHOD&AMOUNT -1
Non-Water Supply Well: ® ft. ' ft. ekd-eAh u fe,( �7'�1sc.�C' �
❑Monitoring ❑Recovery1�1 it ° it. �%ets f�, 4� 'OP
Injection Well- ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
I9.SAND/GRAVEL PACK rf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E1VffLACEMENTMETHOD
❑Aquifer Test ❑StorrowaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
lJ ❑Geothermal(Closed Loop) []Tracer 20.DRaIINGLOG atladtadditionalsheetsifnecessa
FROM TO DESCRIPTION color,hardness,soiUrnrlc a sbe,et
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks)
ft. ft /
4.Date Well(s)Completed:
ft 1�®�° ft �t� rd' c�a,►a ,�`. �✓�r
5a W�11,Loc4tion: Phone #mow�P��1��-l�Q �2
it
Li
Facility/Owner Name FadMyM#Cifapplicablc) ft. ft
ft. ft
Physical Addmss,City,and Zip
ft it
21.REMARKS
Cotmty Parcel Identification No.(PIN)
5b.Latitude and longitude in degree&WrLutes/seconds or decimal degrees:(if well field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): Armanent or ❑Temporary ow-
of ertified WeD Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or W, 15ANCAC 02C.0100 or 15ANC.4C 02C.0200 Well Construction Standards and that a copy
1f this is a repair,ill out known well construction information and arplain the nature of the of this retard has beenpravided to the well orv,rer.
�.y repairrmder#21 remarks section or on the back ofihisfarm. 23.Site diagram or additional well details:
� 8.For Gee robe/DPT or Closed-LoopGeothermal Wells having the same You may use the back of this page to provide additional well construction info
C l construction,only 1 GW-1 is�ieeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remadm Box).You may also attach additional pages if necessary.
1 drilled: 24.SUBMITTAL NSTRUCTIONS
9.Total well depth below land surface: 7 W�p (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3@200 and 2Q100D
yy�� s 7�ta. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /00 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
a_ lfwater level is above casing,use"+"
Bit Off: 0&® 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: -(in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-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 aver 100,000 GPD: Copy to DWI?,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-I611
I3s.Yield(gpm) 130 Method of test: �sr'��°��
70%HTH / OZ DATE SITE VISITED: �' l e�'2 Z-
13b.Disinfection type: Amount:
- VISITED BY: ®M,
Uri rP r -