GW1-2022-04334_Well Construction - GW1_20220408

• ��i;� CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inforrantion:
U I I_-S' 14.WATER ZONES
Well Contractor lume FROM TO DESCRIPTION
G
NC Well Contractor Certification Number -7 Is.
15.OUTER CASING for multi-ra NU' wells ORLINER If Gcable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKIVESM MATERLAL
it. ft. in. O
Company Name it 3 z �+ _ j.s C5 llu16.INNER CASING OR TUBING' eothermal closed-loop) Z
1 I n e FROM TO DIAMETER THICIOVLMM MATE AL
2.Well Construction Permit#: �
Llst all applicaW well construction pei�nils(l,e.UIC,County,Slate,Yarionce,etc) ft g It
in. A t/C-
3.Well Use(checkwell use): ft ft' in. d
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE+ TMCKNESS MATERIAL
❑Agricultural ❑Mimicipal/Public ft. ft. in. f,
❑Geothermal(Heating/Cooling Supply) Rfesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUP
01trigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring r ' - �` x' b7 ecovery ft ft.
Injection Well: -t; f1
❑Aquifer Recharge �p G $ f)�flGroundwater Remediation I9.5AND/GRAVEL PACK rf a livable)
❑Aquifer Storage and Recovery ,.,,❑Salinity Barrier FROM TO MATERIAL n1PLACEMENTMETHOD
It
❑Aquifer Test (�;,�'. ^":��OStoinl ater Drainage
❑Experimental Technology"-,`•''' ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG fattach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retrnn) ❑other(explain under 921 Remarks), FaoM To ft. L DESCRIPTIONccolor b�aLrdnen,:avro�r a .• Sim etr- �L
4.Date Wells)Completed: 3-I r"l72 weu m#A AU.;-011 -7
5a.Well Location: Phone#5-71 n 76.2,28m ft ft
ack
' �f✓L� T't•17✓�Q�'� fitiiLl.'F'Q' ..«�: s
Facility/OvmerName FacilityM#(if applicable) ft. IL
�t t'-"I lew
O ( ft. y ` "`z
r c
ft ft
Physical Address,Ciiy, d Zip "
Q G 21.REMARIGS ' 9C
Ft d �l�
County .. . ' : , Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ut 41"f vl �• t9�w( Ir _ 1
(ifwell field,dnelat/longis`snffeieni) 22. ertification:
4.
,a N W
15a�3y
6.Is(are)the well(s): dermanent or ❑Temporary S ature of Qfftificd Well Contractor Date
By signing thisform,l hereby cert(fy that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 000 ISA NCAC 02C.0100 or 15A NCAC 62C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplain the nature of the of this record 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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to ptrovide additional well construction info
construction,only 1 OW-1 is needed, Indicate TOTAL NUMBER of wells (add See Oven'in Remari,5 Box).You may also.attach additional pages if necessary.
drilled:, 6, 77 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths 1fdiierent(=Mple-3@200'and 2®100D
10.Static water level below top of casing: (ft-) 24a. For All Wells: Original fnnn to Division of Water Resources (DWR),Ifwater level Is above casing,use Information Processing Uait,1617 MSC,Raleigh,NC 27699-1617
"+"
Bit Off: 74b.For Injection Wells: Copyjto DWR,Underground Injection Control(TUC)
11.Borehole diameter: (�•) 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,eta.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing g over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �- Method of test: /9�r���fir!
!7
Disinfection type: 70%HTH Amount: f fj,;t OZ DATE SITE VISITED: On 94
fj VISITED BY: OLI
P r i -+--