GW1-2022-01788_Well Construction - GW1_20220214

nI IL CONSTRUCTION RECORD t'GNV-Ii For Internal Use Only:
L Well Contractor Inforrontiorn
• 14.WATER ZONES _
Well Contractor N �+ y.� •` ,/�^ �'ROT2 TO DLSCRD�ON
c A f `EC E I LV, lF._..ID to.?3 ft. ft. �
AV— .A _p ft. ft.
NC Well Contractor Certification Number f R 4 Z(12? 15.OUTER CASING for multi-used!wells OR LINER if a livable 7K
YADKIN WELL COMPANY,INC. FROM TO DIAMET'ER'. THacamSs MATERIAL
- . Dr�aGprlf,V ft ft. in.
CompaayName 16.INNER CASING OR TUBING eo%ermal closed-loop)
Z.Well Construction Permit#: �
131411 FROM TO DIAKM 1i: THICICMS hATERIAL
�
List all applicable well construction permits p r-fnG County,state,Variance,eM) fr. Z it S�iu. ,p V
3.Well Use(check well use): ft• fr. in.
Water Su 17.SCREEN
Supply Well: FROM i0 DIAMETER SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipaoublio ft. ft, in.
❑Geothermal(Heating/Cooling Supply) AResidential Water Supply(single)
ft. ft. in J
❑Industrial/Commercial ❑Residential Water Supply(shared) 1s GROUT _
❑Irrr ation ❑Wells>100,000 GPD FROM TO MATERW. EMPLACEMENT 1%2ETHOn&AMOUNT
Non Water Supply Well: ft. ft.
430 u rc
❑Monitoring ❑Recovery tt .3(�t ft. •s�l !�
Injection Well: —
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(f applIa1110
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERW', EHPLACEMI;NTN=OD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additioaal sheets if necessary)
FROM TO DESCRIPTION color,hardneu,soiVrock 4 grain sae,etc
❑Geothermal(Heating/CoolingBetrml) ❑Other(explain under#21 Remarks)
AA��
ry ryaG �y : ft. 5I ft• !! 1 o C.ri
4.Date Well(s)Completed: — •''� Well mhO- / ! '� ft ft eaP /Arrf A fr ,%--4o
5a.Well Location: Phone #Sa 8 l `��d� a�0 ft r)1 Q_'S 40 Lr-& �.I&.:
&In L l�[kk 13�ft. 63.ft �� ,
Facility/OwnerN Pacilify]D#(if applicable) ft. ft
ft. ft
—Physical Address,City,and Zip�T ft. ft
�N w� ev 21.REMARKS
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(ifwell field,one lat/longis sufficient) 22.Certification: Q
*eg4SN- Bd r'�. W
6.Is(are)the well(s): permanent or ❑Temporary Si of Ce Jell CEntractor Date
kt By signing thisform,1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or bNo f I SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
Ythir is a repair,fill out!mown well construdion information d explain the nature of the of this record has beenprovided to the well owner.
repair tmder#21 remarkrsedion or an the bark ofthisform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction inh
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: t 1 24.SUBMITTAL INSTRUCT][UNS
9.Total well depth below land surface: _(ft.)
For multiple wells list all depths lfdiferent(example-3@200'and 2@700�For this GW-1 within 30 days of'well completion per the following:
t R�
�?o ) 24a. For All Wells: Original form to Division of Water Resources (DWR), V
if Static water level below top of casing: (ft• Formation Processing Unit 1617 YSSC,Raleigh,NC 27699-1617
Tfwater level Is above casing,vse"+" g � !�. -
11.Borehole diameter: (in.) Bit Off:�(;617 24b.For 11 iection Wells: Copy to DWR,Underground Injection Control (TUC) \
96
Program,1636 MSC,Raleigh,NC 27699-1636 t9
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 departnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA rp
f Permit Program!,1611 MSC,Raleigh,:KC 27699-16I1
13a.Yield(gpm) Method of test: �GE/i`
13b.Disinfection type- 70%HTH Amount: !/+� OZ DATE SITE VISITED:
C�(��& VISITED BY: �p —