GW1-2022-01810_Well Construction - GW1_20220214

b1IN RECORD(Q�t-bl-11 For Internal Use Only:
1.Well Contractor lnformntion:
kCC�f E�Q' c'1S 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name �1r it, I� ft ,7 t/pto
�4j 1A � :.; ft .184 it P31 M
NC Well Contractor Certification Number td �()')') 15,OUTER CASING for multi-raked wells ORLINER if a licable
YADKIN WELL COMPANY,INC. D FROM To DTAM1tTER TffiCrOVEss MATERIAL
...�.n� ft. ft. in.
Company Name 16.INNER CASING OR INGIgeothermal closed-loc
2.Well Construction Permit#: oSS FROM TO DIAMETER TEacim Ss MATERIAL
List all applicable well construction permits(L-e.UIC,County,State,Variance,eta) 1 It I s-/ ft !j in.
. 1008
3.Well Use(check well use): ft ft' in. 1
17.SCREEN
Water Supply Well:
FROI•i TO DIAMETER SLAT SIZE THICKNESS MATERIAL Y'. •`:,
❑Agricultural ❑MunicipaWublic ft. ft.
❑Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Watx:rSupply Well: d ft S� ft Cjncrd S
❑Monitoring ❑Recovery it ft.
N
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater RemediatioII 19 SAND/GRAVEL PACK iia linable
❑Aquifer Storage and Recovery ❑Sal pity Barrier FROM TO TE I E aIACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft'
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothemmal(Closed Loop) ❑Tracer 20.D1tII,I ING LOG attach additional sheets if necessa '•:
❑Geothermal(Heating/CoolingRetrnn) ❑Other(explain under#21 Rematics) FROM TO DESCRn'TiON color,hardness,:oil/rnek a va sae eta
4.Date Well(s)Completed: I o1 3 t i1( Well ID#l777 -FS'"C !4. ft
�ft 30 It
Sac,kr, / fL ft
5a.WeelllLocaatiiow P Ph011E-#
Me, ft. ft
Facility/Owner Name Facility ID9(if applicable) ft ft
fL
�..� 11 V,Boomer, �e J94 ft
ft ft
Pbysioal Addaess,'City,and Zip
21.REMARKS.
•.,County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): Iermanent or ❑Temporary Sigo re of ed Will ontactor Dana
By signing thisform,I hereby certify that the we11(s)was(were)constructed in accordance with
7.Is this a repair to an existing Well. ❑Yes or kfqo ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Stondards'and that d copy
lfthis is a repair,fill out known well construction i lformation ohd explain the nature of the of this record has been provided to the well owner.
repair under 921 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 js needed. Indicate TOTAL NUMBER of wells (add See Over'in Remari Box).You may also attach additional pages if necessary.
drilled:- 1 24.SUBMITTAL INSTRUCTIONS
Cf
9.Total well depth below land surface: 3041 (ft.)
For multiple wells list all depths IIf&fferent(example-3Ua 200'and 2@100D Submit this GWA within 30 d i ays of well completion per the following
24a. For All Wells: Original foam to Division of Water Resources (DVd1t);
10.Static water level below top of casing: w (ft) hlfbrmation Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use
Bit Off: d 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�) 7k Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Coto the
(i.e.auger,rotary.cable,direct push,etc.) county environmental health department of the county where installed d `
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing, over 100,000 GPD:Copy to DWR,CCPCUA
3- Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test:
13a.Yield(gpm) �dli�
70%HTH OZ DATE SITE VISITED:1f/...�� J
13b._DisinRetion type:.. Amount: l j
-- VISITED BY: