GW1-2022-10446_Well Construction - GW1_20221116

WELL NS RUCTION Ri CQ2P LG_YV-1_) For Internal Use Only:
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1.Well Contractor Information:
14.WATER ZONE,S
FROM TO DESCRIPTION
Well Contractor Name
3y36A fL 6dv ft1/y
NC Well Contractor Certification Number I . ft' ft. �—�
`I �n
5.OUTER CASING formniti-ra' wells OR LINER da linable
YADKIN WELL COMPANY,INC. FROM n THICKNESS MATERIAL
ft. ft. in.
Company Name 'lsl-�lti _xr fr J CW S, 16.INNER CASING OR TUBING(Reothermal closed-loop) �
2.Well Construction Permit#: J-6 (r— 'y Jcz 7/
FROM TO DIAMETER I THICKNESS MATMUAL
List all opplicable well construction permits(ie.fllC,County,State,Variance,etc) I Zq it
it ( SD _a (/
3.Well Use(check well use): ft' ft. in.
17,SCREEN <
Water Supply Well: FROM TO DIAMETER SLOTSME THICIC ESS MA '
❑Agricultural ❑Municipal/Public ft, ft,
❑Geothermal(Heating/Cooling Supply) 94sidential Water Supply(single) ft. f in.
❑Industrial/Commeicial ❑Residential Water Supply(shared) IS.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft. Z
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM SAND/GRAVEL TO PACK MATE1.ULe EMPLACEMENTMETHOD 2J
❑Aquifer Test ❑Stormwater Drainage n ft
❑Experimental Technology ❑Subsidence Control ft it a
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
tP
❑Geothermal(Heating/Cooling Rehun) ❑Other(explain under#21 Remarks) FROM TO DascRITlox color,tis rank,:oNrork o sce err
ft ft
4.Date Well(s)Completed: d- 3`Z weulm# ?-/*Z f ft. /
5a.Well Location: Phone # 3.3G' y`2k-1,3kr1 'SI fr. C/J— fr
6/,r CZL fti ly � GnV✓t`t.
Facility/Owne Name Facility M#(if applicable) ft. ft
ft ft
17 IV deli A t_i p..,.• ? f -
Physical Address,City,and ft ft ft
21.REAlARKS ( �r
County Parcel Identification No.(MD - ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r 1 Ct h+
(ifwell field,one lat/longis sufficient) 22.Certification:
] G
6.Is(are)the well(s): permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby cerlify that the well(s)was(were)constructed in accordance with .
7.Is this a repair to an existing well: ❑Yes or �0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
]fthis is a repair,fdl oul brown well construction information and explain the nature of the of this rechrd has been provided to the well awner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.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 TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y L Z (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(Qa 200'and 2©100�
/`�r1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (J (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaler level is above casing,use"+" q
'i Bit Off: `�� /s0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
"�
11.Borehole diameter: (in.)
Pmgtarzr,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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
NC 27699-1611 Raleigh 1611 MSC
Permit Program, , ,
13s.Yield(gpm) so Method of test: s ![;•t'
/• $ ��,aos � o
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
VISITED BY:
Fnnn GW-t arolina Departrnent of Environmental Oualitv-Division of Water Resources Revised 6-6-2018