GW1-2022-01775_Well Construction - GW1_20220214

NVEL L CODS TRNCTION RECORD (G'YV-1) For Internal Use Only:
1.Well Contractor Information: _
�� 14.WATER ZONES _
4"� FROM TO DFSCMTIOT'
Well Contractor Name RECEIVED
NC Well Contractor Certification Number t 15. UTER CASING for niulfi- ed wells ORL tf Gcable
YADKIN WELL COMPANY,INC. f t� 1 FROM To DIAMETER TffiCfQIESS MATEfUAL
ft ft. hi., Company Name t rbfsamN o u"
r 16.INNER CASING OR TUBING eothermal closed-loop)
f 2.Well Construction Permit#: 317 Z d� FROM TO DUMErEIz TffiCIQILSs TtATERLAI,
List all applicable well construction permits(r.e.UIC,County,State,Variance,etc) ft ft ro• r /
t 3.Well Use(check well use): R' R' in.
j 17.SCREEN
Water Supply Well:
pp Y FROni TO DIAMETER SLAT SIZE TRICKINESS MATERIAL
3 ❑Agricultural ❑Municipal/Public ft. ft. in.
J ❑Geothermal(Heating/Cooling Supply) Jiesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
J ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft, ft- Vs 4,"J. Ch !_s1_
❑Monitoring ❑Recovery 3 it ft. 7r
Injection Well: s
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19,SANDIGRAVEL PACK rf a lirs:ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATMR L EIt7PL.ACEMENT METHOD
� ❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
a ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DFSCRIElIDN color,bardnes:soil/ruck type%gr.un sae,etc
4.Date Wells)Completed:ti_3141 .1 WellID# z4ef0-7A!y ,�ft a� ft 6,_v.Il,, A A /
ft T
Phone #1. 0 J-4fy -4Z0 NY S—
5a Well Location: s& q Ae.
°� 1�L°Yh4 �B LlihI —ft ft M 'lip tYo
Facility/Owner Name li/� FacilityM#(if applicable) ?G)ft 5-/f ft- Meg=�>/�i_ ,e
PCO CA� o� ft. �� ft. —
Physical Address,City,an ft. '
-d Zip a O�Q 7 5 —
/ 4 h4. 7.1.REMARKS —
County 01Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(ifwell field,one lat/loagis sufficient) 22.Certification:
6.Is(are)the well(s): A.permanent or ❑Temporary Signature of Certified Well Contractor Date
/ By signing thisform,I hereby certdy that th a well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell out known well construction beformation Ad explain the nature of the of this record has been pravided to the well owner.
repair under#21 remarks section or on the back ofthisform. 23,Site diagram or additional well details'
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bank of this pate to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: J 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this Gw-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3 rQ200'and 1@1001
` 24a. For Ali Wells: Original fi)rrl to Division of Water Resources (DWR),
if Static water level below top of casing: (ft.) Information Processing Unit,1611 IV1SC,Raleigh,NC 27699-1617
If wafer level Is above casing,use "+"
Bit Off: ��6,� 24b.For Injection Wells: Copy to DWR,Underground Injection Contra] (RUC)
11,Borehole diameter: (in-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Ope:a_Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,etc.) county environmental health depa1ment of the county where installed
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
13s.Yield(gpm) 13 Method of test: 416f
rah_Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: `.Z P/- —Zt
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