GW1-2022-04325_Well Construction - GW1_20220408

= I+I+,I, ; NSTRIUC-XIO eT 11�+E CORD(GW-1) For Internal Use Only:
1.Maf-Ow
ontractor Information:
14.WATER ZONES 1
Well C011tractor,leme FROM TO DT+.SCRIPTION
y ft. 9 z
30 3� �#� a7,r� � � i is
NC Well Contractor Certification Number15.OUTER CASING for multi-cased wens ORLINER rf a licable p �
�
YADKIN WELL COMPANY,INC. FROM DI THEMQW60S MATERIAL
it im
Company Name � s S' - 7©lC}1' 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#:W S FAA G13 3$4 3 �� t FROM I TO DUMB= THICXCMS ' NIATMUAL
Lisa all applicable well construction permits(ie.UIC,County,State,Yarionce,etc) / IfL
ft (/ in. Q ? ��e
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROni TO DIAMErER SLOT SIZE THIG7@TE55 MATERIAL
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) Udesidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMM METHOD&AMOUNT
Non-Water Supply Well: O ft. ,3 ft ttk. 6r4V I
❑Monitoring ❑Recovery 3 1 ?' s'' I8 0;k 7 p1
V ,�,1 d y �2
Injection Well: d
ft. R
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bawer FROM To MATERIAL nVI ACEMENTR=01)
❑Aquifer Test ❑Stortnwater Drainage
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Hesting/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIP ON color,hardness.soigsnck aim size,etc.
o 3o ft- -5.11
4.Date Well(s)Completed: n 1t 7.2-1 Well ID# 3® D L157
5a.WellLocation: Phone #-TC. ?,q-/7 3Z 'IS fL 3o2. ff- Gr &
ft. ft
Facility/Owned ame g�t Facility ID#(if applicable) ft. ft _
ft. fL
Physical Address,City,and Zap v)('1 ft it
Yea k .n V 21.REMARKS n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrems minutes/seconds or decimal degrees:
(ifwell field,one IstAongis m icient) 22.Certification-
3G, ,2 y 9?H N 80 �oti I o w 17-22,
6.Is(are)the well(s): dIrmanent or ❑Temporary Signature of Certified Well Co for Date
By signing thisfarm,1hereby certJYyat the well(s)was(x)ere)constr thucted in accordance with
7.Is this a repair to an existing well: ❑Yes or MR'o 15ANCAC 02C.0100 or 13ANCAC 02C.0200 Well Construction Standards and that a copy
If thin is a repair,fill oul known Well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks secttan 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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages iFnecessary.
drilled:, 24.SUBM TTAL INSTRUCTIONS
9.Total well depth below land surface: ®� (f") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3©200'and 2©100D
i.
0 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
Ifwater,level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: J� .� i� 24b.For Injection Wells: Copyito 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
(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 producinI over 100,000 GPD:Copy to DWR,CCPCUA
�� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Xield(gpm) �V Method of test: � ��✓�
13b.Disinfection type: 70%HTH Amount: oC G OZ DATE SITE VISITED: ®��'°li/ lam' f `✓