GW1-2022-01804_Well Construction - GW1_20220214

WELL LL CONS MI UC jTION iRJ (CORD(daub'-1) For Internal Use Only:
1.Well Contractor Informntion:
Jtf'('y W QT�1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION •�i
1465
aLks"aA RECEIVED- f ft. ,s c
FM
NC Well Contractor Certification Number
FEB 1 4 () � 15.OUTER CASING forniul&-r�sedwells ORLINEA ifa livable
YADKIN WELL COMPANY,INC. 2.2_ FROM To DIAMETER THICTINEss MATERIAL
ft. it. in.
Company Name Inbntatian Pfocs"Ge p U)
16.INNER CASING OR TUBING'(geothermal closed400 ) Q
2.Well Construction Permit 0 W FROM TO DIAMETER TMCIGMS MATERIAL
jList all applicable well construction permits fl.e.UIC,County,State,Variance,etc) ft G ft G l�ti m. 5 VQ v
.� 3.Well Use(checkwell use): ft. ft. m. �J
Water Supply Well: 17.SCREEN
FROM - To DrAMErER SLOT slzE THICfINEss MATERIAL
a ❑A.gricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS GROUT
t ❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT 1MET130D&AMOUNT
Non Water Supply Well: o ft' 3 ft. 146k F1,j_5 Pbur,J
❑Monitoring ❑Recovery 3 " 271 ft &tape 6rodl Pu L4 ba S
Injection Welk
ft. ft
❑Aquifer Recharge []Groundwater Remediation
❑Agnlfer Storage and Recovery ❑SalInityBarrier FRo11SAND/(RAVEL PACK MATERIALe ErM METS EMPLACNTOD
❑Aquifer Test ❑Stormwater Drainage ft• ft-
❑Experimental Technology ❑Subsidence Control ft- ft. Z
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLAVG LOG attach additional sheets➢f necessa
� ❑Geothermal(Heating/CooIing Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIMONcolor hu.-dness,soil(mck type,gmin Arse,ete
�. o ft. L 3 fL,, ®a`t o '
4.Date Well(s)Completed: 7 el J Well ID# D-9' 63 ft- SO ft- �-
Sa.Well Location: Phone #X��5^loQl 3`13 ft
ft. ft
` Facility/Owner Name Facility ID#(if applicable) ft ft
O L .15 ld o a m u. led �o �ev,
C ft. ft
Physical Address,City,and Zip 900 GO ft ft
( o f/h c f 21.REALU (S
County /' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wongis sufficient) 22.Certification:
3l� '2,)�N Fsl l S �,.� W Ll"oDate' S �z
6.Is(are)the well(s): ermaneut or ❑Temporary Signatn a
11' f Ce 'iied Well Contractor
rm
By signing thisfa ,I hereby centfy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or $No ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
If this is a repair,fdl out lmown 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.
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 info
construction,only 1 OW-1 is tirded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarla Box):You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5�� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(ewmp/e-3(c�200'and 2©100D
ft�O 24a. For All Wells: Original form. to Division of Water Resources (DWR),
if Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wafer level Is above rnsing,use"+"
11.Borehole diameter (in.) Program,
Off: G'040 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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 Q
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depl'artment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciva,oyer 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) t S Method of test:_ / /" I
131J._M—sinfection.tyke.•_ % Amount: ^^ T
70 HTH d d OZ DATE SITE VISITED: r%
VISITED BY:

1 ,CONS TRIUCTION REiCORD(GW-1) For Internal Use Only:
i
1.Well Contractor lnformntion:
���t/► f� w,`e� f"i t 11r+w+. FROM
WAiEIt 2A1VLS
Well Contractor Nam p -1.N i ' 1-) EOM "- DRUSaUY'r10N (ti
f tD 4' �ill> sCIt
NC WellConttactor(:erti$catianN�ber 15.'OUTERCASING for multi-caged'w RLINER tfa Hcable V'
YADI4N WELL COMPANY,INC. Irlf�lAl�Dt1 Pf:, '''•'l'1i tirw FROM I TO DIAMETER TffiCIOVESS MATERIAL
IL ft
Company Name ��� `` a S'-T
('Lid �t_J. 3 16.INNER CASING ORTUBING eothermaldosed-loo
2.Well Construction Permit#:; o `T FROM To I DLOMTER I TMCICRESS MATERIAL
List all applicable well construction permits(4e.IIIC,County,Statq Variance,aw-) ;I-ft ,r Ztr P t✓L
3.Well Use(checkwell use): ft ft' `n
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TI ICKNI SS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) • ft. ft.
❑Industrial/Commercial QResidential Water Supply(shared) Is.GROUT
01rrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply
Well-0 ft. ft. e -
❑Monitoring ❑Rewvery ft
Injection Well: tt ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK sf i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMFLACEMLNTMEMoD
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experime tal Technology ❑Subsidence Control ft. ft
❑Geothermal(CIosed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION Wor,hardness soillrocktype,gridn sae,eta
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remadm) Oft, r
4.Date Well((s)�C�ommpp`leted: Well ID# b J It J 0f ft' Mee r O
5a.Well L;;�W."►aA:;t"'.,'7.' Phone # f0 • 7z,0f.. 7/ Z /yl d v
Facility/ ame' act C aPPli e) ft. ft �4c
• '` t ti' ft ft
\�
FhygdEa?.ddce53;G4ty.and Zip ft ft.
" Ka;
pointy Parcel Identification No.(PIN)5b.Latitude and longitudel idegrees/minutes/seconds or decimal degrees: ��
(ifwell field,one lel?16rigis snfhcient) 22.Certification:
3 G .2 o sY 8'9 N f0 Sq W J„7-add
6.Is(are)the well(s): ermanent or ❑Temporary S' a of C d W Con ctor Date
By signing thisfa m,I hereby certify that the well(s)was(were)constructed in acconlance with
t" 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and That a copy
7.Ia'this a repair io an eti4stingwelI;. ❑Yes or �No
lfthb is a repair,fd1 out known well construction information anrerplain the nature of the of this record has been provided to the well owner.
repair under421 remarks section or on the backpfthisform.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells haviiig the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 it needed. Indicate TOTAL NUMBER of wells (add See;Over in Remarl Box):You may also attach additional pages if necessary.
drilled: l 24.SUBII�:INSTRUCTIONS
Zlgq9.Total well depth below land surface: (ft') Submit this 6W'1 within 30 days of well completion per the following:
For multiple wells fist all depths if different(example-3©20 'and 2@1001
9 24a. For All Wells: Origmal;fonn to Division of Water Resources (DWR),
10.Static water level below top of casing: G (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use'+" C
J$� 24b.For 14jeetion Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter.. (in.) Bit Off: 47s Program,1636 MSC,Raleigb,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
`. 13a.Yield(gpm) jb 3 Method of test: Q clh Permit Program,1611 MSC,Raleigh,NC 27699-1611 1_
DATE SITE VISITED:! OZ" S 2p v j
13b.Disinfection type: 70%HTH Amount: �, � r���

!
mad �_ �1_u u _
._____._. 1�_._..__..___ EIVED-. 1c
We11 Contractor N�e C� bi•.Ct.l TO i.FErC.1•Tinit
FR 1 I
NC Well Contractor Certification Number 15.OUTER CASING for mull-rsised wells OR LIIVER if a licable
YADKIN WELL COMPANY,INC. tn�Pr• '•• PRon2 xo n1An�r>R T1DclavEss TaaRUL
^'oAja ft. ft, in.
Company Name 16.1NNER.CASING OR TUBING(Eecthermal closed-loon)
2.Well Construction permit#: N FROM TO I DIPMTLrR T1irCftNESS I MATrtnrAT.
List all applicable well construction permits f e. ,County,State,Variance,eta) G ft. in. `/l
3.Well Use(check well use): � ft. ft. in. vV
Prater Supply Well: 17.SCRF.;<,.I 1
FROW 0 DIAMETER I ELOTSIZE I TiRCIOtLSO n1YT'iPi:i
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ,residential Water Supply(single) it, ft. ;in.
OlndustriaUCommercial ❑Residential Water Supply(shared) lg CRUUa m
❑Irrigation ❑Wells>100,000 GPD Feord To RATCRraL EMPrAC>PTENT n•>=T90D f al:roulvr \
Non-Water Supply Well. oil. ve ft. P e u rew
❑Monitoring ❑Recovery ft t7 i ft V
Injection Well:
ft ft.
❑ uifer Recha
rge urge ❑Groundwater Remcdiatian
- 19.SAND/GAITL PACE:(if ap icable)❑Aqulfer Storage and Recovery pSalinityBarrier
FROM To MATERIAL RMeLAa-:rIM? n•MHOD
® ❑Aquifer Test ❑Stormwater Drainage ft. ft.
U ❑Experimental Technology ❑Subsidence Control & fL
V ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if oeressa •)
IIROA1 TO DESCRIPTION color,hardness soillradctype, sae,ete.
❑Geothermal(1Teating/Cooling Return) ❑Other(explain under#21 Remads)
O It ft. 50a`l
�1 4.Date Well(s)Completed: Well ID#
5a.Well Location: Phone o ;I► U`
fL ft.
V Facility/Owner Name Facility]D#(if applicable) ft. fL
L r`al, tR czf cu.1jQyS,Nc a 035 ft ft.
f Physical Address,City,and Zip & ft
• !- 21.REIMAPM
County Pm-cal ldentificatimNo.91N) Jt: re)Wt. .- ec
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is snfficiem) 22,Certification: Q
N Vl 4e4 W -11•do
6.Is(are)the well(s): Permanent or ❑Temporary Si o Well Contractor Date
signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an ertisting well: ❑Yes or ANo 15ANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explaln the nature of the ofthis record has been provided to the well owner.
repair under 921 remarkysection or on the backafthisform." 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 info �p
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER ofweM (add'See Cher'in Remarks Box).You may also attach additional pages if necessary.
drilled:. i
4 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 2� �• A) i
For multiple wells list all depths IIf&Jerent(example-3@200'and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
�tf a 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,I611 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter (�) Bit Off:1Q OO T 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
AIR ROTARY Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: 24c.For Water Supply and Open,-Loop Geothermal Return Wells:Co to the
(Le.sugar,rotary,cable,direct push,etc.) county environmental health department of the county where installed py
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.veld(gpm) / Method of test: Q��' Permit Program,1611 MSC,R�jaleighl�NC 27699-1611
70%HTH L'4 OZ DATE SITE VISITED: / 7 . 02 ( C
13b.Disinfection type: Amount: 7p
VISITED BY: �B
Form OW-1 rental Quality-Division of Water Resources Revised 6-6-2018