GW1-2022-01802_Well Construction - GW1_20220214

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W CE C DNSTRNCTION RECORD(GH-D For Internal Use Only:
I.Well Contractor information:
ll
aW—i/13 14.WATERZOIC-S
Well Contractor Name—r FROA4 TO DESCmPTiON
g ft. go ft. �y a
NC Well Contractor Certification.Number EEC E•VE R 47&ft I�y GQm
FEB15.OUTER CASING for uiulfi-cased wells)ORLINER if a livable
YADKINW LLCOMPANY,►NG. F .y 4 ? FROM TO DUIVIRTER THICEQrEsS M.&TERrnL
! 2.2.. L)
Company Name Y L� 8 y ft 651* m. � '88
f�.s�+
�y on P Aft WS.INNER CASING OR TUBING(geothermal closed-loop)
(/a
2.Well Construction Permit#: L" 15 g D4VOISOG EOM TO DIA1vIE R I THICIaiEss MATERIAL
List all applicable well constructlon permits ri.e.EUC,County,State,Variance,etc.) fr• ft in.
3.Well Use(checkwell use): ft ft. in.
Water Supply Well. FROM TO DIAMETER SLOT SIZE THICIOHESS MATERIAL
OAgricuItural ❑Municipal/Publiq ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft. ft.
❑IndustriallCommm- ial ❑Residential Water Supply(shared) 18.GROUT i
L�
❑Irrigation ❑Wells>100,000 GPD PROM TO MATEMAL EMPLACEMENT hMTHOD&AMOUNT
Nan-Water Supply Well: Phi Paum') C�
❑Monitoring ❑Recovery it C)(� ft. Quick6rad puimplJ 3 b4
Injection Well: S
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I:MPLAC:EMENTMLZ•HOD
❑Aquifer Test ❑Stomrwater Drainage it ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetom) ❑Other(explain under#21Remarla) FROM TO DESCRIPTION color,hardness,sc!Vrork a M.insia.ete.
ft' 72 R' O i
4.Date Well(s)Completed: ��'I Well ID# D-S .?, '7 8 it. /0601t
Sa.WellLocation: Phone # `lo 1+ 6 �r/.4orJd ft ft
ft it
Facility/OwnerName PadWyID#(if app& le) ft ft
• tau w�` r v � • W. fln �C ft. ft.
Physical Address,City,and Zip ft ft.
21.REMARKS C
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: �+
3 6 1 �7`6,. N � g 5�, �l W 14 32
6.Ls(are)the well(s): 0Permanent or ❑Temporary Sign of Ce tified Well Contractor Date d
By signing thisform,1hereby cert]ry that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or XTo 15ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair carder#21 remarks section or on the back of this form.
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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIOPTS
9.Total well depth below land surface: I01,r) (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdifferew(example-2@200''and 2©700�
lDa ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Tfwater level Is above casing,use"+"
11.Borehole diameter- (th_) Bit Off: [o. 10` 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636MSC,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
Permit Prograrn,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /Z Method of test: Q,H
13b.Disinfection type•_ 70%HTH Amount: p OZ DATE SITE VISITED:
PLi rt- ' VISITED BY: (J --- n-