GW1-2022-06384_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD f gW-1) For Internal Use adl
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1.Well Contractor Information: srL
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Lid �Jf ia�/ F'U by 1a.WATER ZONES
FROM u TOE S f `MZSCRIPTXON
Well Contractor Name
T
NC Well Contractor Crstification Number 15 OUTER CASIlVG'forrmiilh sed;wells!OWLINERf d;a Wilil'e
YADKIN WELL COMPANY,INC. FROM .To; ""..�DIANarcER S�! �
Company Name l✓t r�x ". _..rrlll
16 IlMM CASING; r G "thermalrclasedaoo
2.Well Construction Permit#: ®e'ej oM aTo aD7AMmmtOdl>ETffiCin+mSS>�IMATL�It7itL
List all appllcab/e well construction permits Xk Wa County,Staff;Variance,etc) ft.
3.Well Use(check well use):
€-
Water Supply Well: 17SCREENFnoM ..ToM�1plkMErER1iQ msroT zTlazetavassarl s' rERti►L�
❑Agricultural iUPublio
❑Geothermal(Heating/Cooling Supply) 2sidentoial Water Supply(single)
❑IndustriaUCommert ial ❑Residmrdal Water Supply(shared)
1B:GROUT:
01irrigation Dwells>I00,000 GPD TROMA DN"IRCEM iMETHODIXA14IUONTS
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge E3Groundwater Remediation 0
19 5A1tID/GBAVELgP'' �'da licsble
❑Aquifer Storage and Recovery Malmity Barrier 'TROMzMa WON >1MATERIAL't "''..�*EMYL CMyMNT- Ontltltltlttr•
❑Aquifer Test [IStormwaterDrainage � r
❑Experimenta]Technology ❑Subsidence Control t y
❑Geothermal(Closed Loup) ❑Tracer. ORDRlI,TINGLOG'' ehxiddibonel�hxts,;rfa a
. � ,,: �FROMl�Y IaTO t�)DESCRD?TiON'mlocRiarda`�ToVroek �"-"'1"'Teh'?1�
❑Geothermal(Reating/Co5olingRetum) ❑Other(explain under# x§?1;Rt>merics) ft. .
d�� � ���
4.Date Well(s)Complete Wel1ID# 9 ,SN RE v
sa wellLocatian: Phone #33G gC � � olt ar
Facility/Owner Name Facilfly (ffplrcable")' ft'
J l
Y
Physical Address,City.and TaP k ft.
2VREMARKS 01'Ili:?Rug.n.7D
rr.v�p.
County Paznel TdanYdication No.MN) *;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tfwellfieI onelat/longissufficient '
(' 4 ) 22Cer"fication: 0'
10
no
6.1s(are)thewell(s): dPermanent or ❑Temporary Srgeafii j'ofCertifiedW.ellrGoatrac Dlite
By slg`n g thisfonn,l hereby certdy Thal the,well(s)Wr,fwere)construcmwxa in,aceorrlm�ce with
7.1s this a repair to an erasting well: ❑(es or, )W0 15ANCACO2C 0100`or�!SA�NCiiC'02C.0200 it'e0 Constructlon Slmrdands and.that a capy
If this it a report,fit!out lmown well construction Information and plain the nature of the aphis rewr�d�has bemlrravlded fa the wail;owner
repair under$2lremarkr section oron the back ofthisfomr.
23.Srte'rdiag am or additionalwell details:
a:ems
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You muse the beck of this page to pmvide adrlitional well construction imo
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER ofweIIs (add See Over'in Remarks Hox).Yourmay also attach add gnat net csery.
drilled: s7 g1VMlsrrar:•iil!ISTRUCTIONS
9.Total well depth below land surfacer (ft) fi tr.I >
For multiple wells list ell depths ifdifjerent(example-3@200'and 2Q100) 3ubmlt tbi8-GVh1 within 30 days.of well completion per a following:
�� 24a'I?ar All Wells: Original form to Division of Water Resources
10.Static water level below top of casing: (ft.) lnfoimatron Pmcessing Uait,16,17,MSC,Raleigh,NC 27699-161>7
Tfwaler level is above casing,use"+' i
Bit Off: `S' 7�� 24b FoIatection Wells:,�C,._opy to;DWR,Underground 1ntion Clatter(IiJC)
Il.Borehole diameter: ti
Prod,1636 MSG�Raleig"'Ib,NC 27699-1636
*'
12.Well construction method: AIR ROTARY 24c For Water:Supply andtOpen-Loop GeothenmalRetura Wells:Copyto the
(i.e.auger,rotary,cable,direct pusb,eto) courlty emnvnmenffiI health7dparhiient,of the county w}ieieainstelled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water VYe1ls�producln�:oyer100;000 GYD:Copy m DWI,CGPCUA
PmnitPmgram,�,161IpMSCAMergh8NC27699`161111
13a.Yield(gpm) Method of test: n/
� DATE SITE VISITED: %Z. /Zl I
13b.Disinfection type: 70%HTH Amount: OZ
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