GW1-2022-10363_Well Construction - GW1_20221115

i
W QONS TRUCITT+C N RECORD (GW-1) For Internal Use Only: �
1.' ell Contractor IPEer®ation: V
t -e r�,.�_ 14.WATER ZONES
l`.Jell Contractor Nar&e FROM TO DESCRIPTION
73o35/- ,4
NC Well Contractor CeitificationNumber
IS.OUTER CASING for multi-cased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffirsoNEss MATERIAI,
Company Name 16.INNER CASING OR TU13ING eothermal closed-loop)
2.Well Construction Permit#: ��'w L Z��oG L-1 FROM TO DIAMETER THICIONEss MATERIAL "'�
List all applicable well construction permits(i,e.UIC,County,Slate Variance,etc)
ft ft. in.
3.Well Use(check well use): ft ft. `n
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICICNESS MATERIAL o
❑Agricultural ❑ icrpal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) L�l'Residential Water Supply(single) ft. ft. in. V
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I / D ft. fr. •I_ Clt �� t 1��
❑Monitoring.L ft. ft.
Injection Well: 1
❑ N�v 6Aquifer Recharge oleal v>}tcr Remediation 19 SAND/GRAVEL PACK if a livable)
❑Aquifer Storage and Recovetys :> i �;s FROM TO MATERIAL E717PLACEMENT METHOD
❑Aquifer Test IrnOrt�;ai�.
DVJfl=t-Jfwater Drainage fr- ft•
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEscTurTTox earns,tarancss,:cSurnrk a crse,efo
fr.
0/204t 902— a ft
Ste,' f oe
4.Date Well(s)Completed:` Well ID# 2 9 fr ft Grwa ; / L
5a..Weelll Location
- � Phone #��A. • 2��-S7t+� fL
^ q i It
kue
IL
Facility/Owner Name Facility ID#(if applicable) 10,2. "L 7a 'L tl !( It
Ilea lLCJ, L100---lL Del +4,ty� ft. ft.
Physical Address,City,and Zip
- - - ft ft
2 .4 REMARKS
�r� sown S •
County Parcel Identification No.(PIN) 4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/longis sufficient) Certification.
?,v. W( -K-b N la'? g5' W � ������
6.Is(are)the well(s): QPermanent or ❑Temporary Sign ed Well Contractor Date Q
y signing thisfarm,I hereby certdy that the we11(s)was(were)constrvcted in accordance with (�
7.Is this a repair to an existing well: ❑Yes or BPfo 15ANCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy �l
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. Z
23.Site diagram or additional well details:
S.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�rlceded. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:, / 74.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / VO4, (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diyerent(erample-30a 200'annd 2Q100�
Co ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water lave]below top of easing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use 11, /
11.Borehole diameter: Bit Off:(�, D�� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
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: 4d. t producing o 0 Z For Water Wells prod �over 100,00 GPD: Copy to DWR,CCPCUA
3 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of test:
o DATE SITE VISITED: '7— 2C Z�
13b.Disinfection type: 70/o HTH Amount: "�� OZ
Pry cP- —
VISITED BY: bi
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