GW1-2022-03402_Well Construction - GW1_20220315

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I WELL CONSTRUCTION [RECORD LqW-D For Maternal Use Only:
1.'Well Contractor Information:
14.WATER ZONE'S i Well Contractor a FROM TO I DESCRIPTION
I / 00,9r-1� tom
NC coca S cation Number /p y/O d 4- I `� I
1S.OUTERCASING formnlfi-cas ens ORLINER da licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiCENESs MATERIAL
ft - it. i in.
Company Name
p 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Peimit#: ��7 RI��O FROM TO ft X)IAMETER THIC10ui s T7ATMRKATMERULAL
List all applicable well construction permits(ie.LUCiouro,State,Variance,etaJ In. /Q .I 'n' SD�- O Pft
3.Well Use(check well use): ft. is
Water Supply Well: IROOM�L TO DLkbU , SLOT SIZE THICKNESS
DAgricultmal ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) kkesidential Water Supply(single) . ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
01irigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well- (�ft. y it •IeA but,n(
❑Monitoring ❑Recovery ft. a2' ft. t�
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation '
19.SAND/GRAYELPACK da livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage R ti
❑Experimental Technology ❑Subsidence Control ft ft.
OGeothennal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooimg Rote m) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION corer,hardness,so-Wrock ain size,etc. f
4.Date Well(s)Completed: d� O'a Well ID# - �f ft q 5" m eel ✓� r'C0
5a.Well Location- / Phone # 33�v'$9� Ir8f /ys l05D M !'�7'eo V i Al
A Gca �� Ir ,w • �SOft /l/0� /y�4/
Facility ID#Cif applicable) ft ft
Facility/Owner Name --
ft. fL
ft. ft.
Phydell Address,(Sty,and Zip We6 J119Fj
{ (`A 21.REMARKS w
bS - 3l'cb' Xf��r'; ` � ���,'?/ rr to k
County Paine]Identification No.(FIAT) p S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3 G l 4 d 2�G N T 1 4 5./S 73 W
6.Is(are)the well(s): kermanent or ❑Temporary Vfture of' edified Well Contractor Date
By signing th lift rm,I hereby certify that the well(s)was(were)constructed In accordance with
7.Is this a repair to an ousting well: - ❑Yes or *0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information anderplain the nature ofthe ofthis retard 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 GeoprobeMPT 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: ( J 24.SUBMI'TAL MSTRUCTIONS
9.Total well depth below land surface: /• I/ O'�- (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths fdiferent(eromp/e-3(2r)200 a�ndd2®100D
10.5taticwaterlevel below top of casing: .7 / ? (ft) 24a• For All Wells: Original form. to Division of Water Resources (DWR),
10.Static
tic Is above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwai11.Borehole diameter (in,) Bit Off; 'j,91 5 24b.For Injection Wells: Copylto DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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 depaihnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producini river 100,000 GPD:Copy to DWR,CCPCUA
4. ? Permit Program,1611 MSC,Raleigh,NC 27699-1611
1.3a.Yield(gpm) 3 Method of test: Q/tY C _tw
13b.Disinfection type: 70%HTH Amount OZ DATE SITE VISITED; ��
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