GW1-2022-03412_Well Construction - GW1_20220315

%-WELLCQNSTRU TION RECORD(G W-1) For Internal Use Only:
I.Well Co, tractdr Information:
(I ✓� ' (z7-V. 14.WATER ZONES
Well ContraetorName ft FROM To nFSCRUMO/N / s
t)/y Lf ft. /'� s i�`�G u' i
`l Q I`1 y ft ft �C� �.(r r tr'
NC Well Contractor Ccrtifirzt1=Number 15.OUTER CA.SIIN for mulfi-cased�v OItLI1NEf d e mble
YADKIN WELL COMPANY,INC. FROM To DLAMSTER THICKNM MATERIAL
ft, ft. in.
Company Name J 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: I /16/� FROM To DrAn1TER 'rrMMctavFss t
List all applicable well construction permits rz.UI aunty,State,Parlance,etc) � Lq fi /`' in. �j1 r
3.Well Use(cbeckwdI,use): R ft m
Water Supply Well: 17.SCREEN
pp FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ktesidential Water Supply(single) ft ft. in•
❑Industrial/Commercial ❑Residential Water Supply,(shared) 1B.GROUT' _
❑ � ❑Wells>100,000 GPD FROM TO ,MATERW. EMPLACEMENT]METHOD&AMOUNT
Non-Water Supply Wcll: g ^- ft. ft. `�' C C %D, . 116rR 'd
❑M g t rlonitorin �"d C`sovry @ iw g; l
fe•�! !/A= P
Injection Well: nppt ``jj422���
❑Aquifer Recharge Mt7f3cL�wa'tXI M'diation f3
19.S6ND GRAVEL PACK rf a livable) w t
❑Aquifer Storage and Reoavery I]S F FROM TO MATERIAL. EMPLACEMENT METHOD +�
❑Aquifer Test R' B• S
❑Experimental Technology ubsidence Control ft it
❑Geothermal.(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necrssa
❑Geothermal(Heating/Coollug Return) ❑Other(eiplain under#21 Remarla) LraoM, To DsseRIPTION �t°r,baran�:.:°sur°�x e a cae ecc
® ft.
4.Date Well(s)Completed: -? )X Well ID# Rft
"1°-✓! o'�.� f"��B ��
'' � ' �► ft �gft f
5%Well Location:; Phone #3 ��
�►ml l�'"�, oc.�
Facility/Owner?Qeme Facility 1D#Cif applicable) ' ft' (1e1 c F'C• /c p e
v: �- j e{ ft. I a� I A 4641' ;ter.' ,.
1 , ..
ysioalnaaress,'`Caty,mmdzip f1 � a%Ur)e f fL
ice[ ��• •i:, •�rk
21.RrrivrARTCR .
County Parcel Identification No.0?1N) �� m °�' �'�' bi` "'�`�U'' .��'1 oe✓E ��
7►1 L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i- —
(if well field,one lat/longis.sufficient) 22 Gertiflcation'
6.Is(arc)the well(s),--f#ermanent or ❑Temporary Signature of Certified Well Contractor; Date
r+
By signing thisform,]hereby cer*that the well(3)was(were)constructed in accordance with
7.Is this a repair to an undsting well: ❑Yes or Ia 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standardr:6nd th�tta copy
this is a repair,fill out known well construction information and erp/ain the nature of the .of this record has beer provided to the well owner.
1j t' 6:J1
t reparr render#21 remarks on or ks section an the back of this form.
° 23.Site diagram or additional yell details:
r 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
is needed. Indicate TOTAL NUMBER of wells (add See Over'in RemadO;Box).You may also attach additional pages ifnecessary =-�
drL3led; b� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 t \ (ft.)
For multiple wells list all depths tfdifferent(example-3Q200'and 2©100� Submit this Gw-1 within 30 days of well completion per the following:
(ft.) 24a. For All Wells: Original form to Division of Water Resources (1) R),
10.Static water level below top of casing: Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
lfwaler level is above casing,use"+" )
�1
(�) Bit Off: 6•, � ��^ 24b.For 1niecflon Wells: Copy�to DWR,Underground Injection Control(TUC)
11.Borehole diameter: Progr-arn,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY M�s
f, 12;Vell 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 depafttrient of the county where installed
R WATER SUPPLY WELLS ONLY:FO 1
', ,24d.°°For Water Wells producing o`ver 100,000 GPD:Copy to DWR,C CPtCUA
r Pemut Pmgram,1611 MSC,Raleigh,NC 27699-1611
1 ` r
I 13a.Yield(gpm) Method of test
70%HTH OZ DATE SITE VISIT
13b.Disinfection type: Amount: _ i. w