GW1-2022-03415_Well Construction - GW1_20220315

L91-I&C LION RECORD (GW-1) For Internal Use Only:
"1.Well Contractor Information: 4
� p� 14.WATER ZONES r
Well Contractor Name FROM TO DESCRIPTION.
,j , ®3 ! V ft. ® fr. g �140- Nil . . „ S3 y�
i NC Well Contractor Certification Numbs v ft• 2 Z L7�' "ti '�0 7�'�® ®y v. `�*
15.OUTER CASING for multi-ca ed wdls ORLINFdt d a lira e
YADKIN WELL COMPANY,INC. FROM TO DUKWMER TffiCBTVPsSs. WATERUL.
ft
Company Name q y,' 16.INNER CASING OR TUBIIYG(geothermal closed loo s`
Z.Welt Construction Permit#:2-1 - I " yV �}�'�� 1 FROM To nIAMSrSR TMErams: UTMUAL,
List all applicable well constructlon pw7ils rix.EUC,County,State,Yariance,etc) ft g 0 0 in. �t�
s 4 '16 G N/.
NU
3.Well Use(checkwell use): ft ft.
17.
Water Supply Well: FROM TO DIAKr= SLOTSIZE TH1C1CNC9S MATERIAL
❑Agricultural *Iinicipal/Public r
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPPIY(single) '
❑Industrial/Commercial ❑Residential Water Supply(shared) l r tp
❑Irrigation ❑Wells>100,000 GPD B•GROUT „T,4
FROM TO MATERIAL ISMPLACEMENTT4Lr'[HOD tAMOIINTd 1��lt�
y,
Non-Water Supply Well: Q it ft. H [�•, ��t
❑Monitoring ❑Recovery ft. ft. A
Injection Well: ft.
ft.
❑Aquifer Recharge ❑Groundwater Remediation Sr
[]Aquifer Storage end Recovery ❑S _19•SAPID/GRAVEL PACK if a likable ! ,
Quife rage ery allmty Barrier FROM TO MATERIAL LrMPLACCMLNTMErHOD
❑Aquifer Test ❑Stormwater Drainage oz
zn
❑Experimental Technology []Subsidence Control 20,00000Fft ",001ft /0,1l i
❑Geothermal(CIosed Loop) ❑Tracer C-20.DRILLING LOG attach additional sheets if necossa { �
❑Geothermal(1leating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESC[=Ox color,hardness saahoctc *etc
4.Date Well(s)Completed: ®—Z We AA
ll D# 0 7 R ,;�,•� � S` `' a �
�'4se .ir{� Ar✓ ft fk tws �
52.Well Location: Phone # �.fc��rc7-6 a t,�- 12•T� � _ , V
iJ f p
ft —I y!� �7a! _ C�/�aA.-
Facility/Owns Name 1+�ID#(if applicable) '11L-ld
It �fJ ft* � r ��r�� ,a t o
/ -}�. L ft•
aoA
ye- IgJ4�
Physical Address,City.and ZIP a r ..y I[J, ft. ft
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9~r _l 21.REMARKS
County Parse]Idantification No.(PIN) ttAMAJ � t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^' -
(ifwellfielcionnee lat/longis sufficient) 22.Certification:
76 / Ti �-J N 7 W
6.Is(are)the well(s): 4ermanent or ❑Temporary Sigaatnre of Certified Well Contractor Date
By signing this form,l hereby certify that the well(k)was(ier)constructed in accordance wrth
7.Is this a repair to an existing well: ❑Yes or �Io, 1 SA NCAC 02C.0100 or 1dA NCAC 02C.0200 Well Construction&imdards and than a copy
® If this is a repair,fill out known well construction information and explain the nature ofthe of this record has beenpravided to the well owner.
repair under#21 remark section or an the back ofthisform. 23.Site diagram or additional well details
.�-
S.For Geoprobe/DPT or dosed-Loop Geothermal Wells having the same stiucti
You may use the back of this page to provide additional well conon mfo
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: a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.) fI
For multiple wells list all depths ifdiferent(example-3@200'and 2@1001 Submit this GW-1 within 30 days'`of wr11 completion per the foilowtng:, 1
`� I
10.Static water level below top of casing: T (ft.) ems. For All Welts: Original form to Division of Water Resources (DWR),
Ifwater level Is'above casing,use"+" Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
7 O
11.Borehole diameter: (in.) an Off: -7 /O 24b.For Injection Wells:Copy to 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
(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
O t✓/�o Permit Program,1611 MSC,Raleigh,NC 27699-1611 e
13a.Yield(gpiL, Method of test:rr8
Q
13b.Disinfection type. 70%HTH Amount: OZ DATE SITE VISITED:8
Pri rP Aid y- r� VISITED BY: