GW1-2022-06536_Well Construction - GW1_20220603

`�'WLL CONS TI RUCTION RECORD (GW-1) For Internal Use Only: �
1.Well Contractor Informntion:
✓'G 19.WATER ZONES k _
FRom TO D CRIPTION Z
Well Contractor Name 'r ft. f h
S ft. 3S�d ff.
NC well Contractor Certification Number 6
1.5.OUTER CASING for multi-cased wells ORLINER d a licsble
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THIC KMS MATERLIL
ft, ft 'in.
Company Name
9197
� 16.INNER CASING OR TURING 'eothermalrlosed-loo )
2.Well Construction Permit#. FROM TO DIAMEr Ten THICIINFSS MATERIAL
List all applicable well construction permtls(La.tnG County,Stale,Parlance,etc) R 7 U i Zt <!
3.Well Use(check well use): ff• ft, in.
17.
Water Supply Well: rROArTO DIAMETER SLOT SIZE TMC[GaSS MATERIAL
0A.giicuItural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1B.GROUT
❑Irlgatim ❑Wells>100,000 GPD FROM TO MATERIAL E//MPt�LACEMENTMETHOD&AMOUNT
Non-Water Supply Weil: O ft. ft. 614
❑Monitoring ❑Recovery S it ft 16t
Injection Well:
ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVEI.PACK(rfapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Storrawater Drainage ft �o
❑Experimental Technology ❑Subsidence Control ft it:
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Ratum) ❑Other(explain under#21 Remade) FROM To DESCRIPTION color hoidaes,soflimt c e, : etc
c� f 5" S 't!
o S'�' .S&,
4.Date Well(s)Completed:J x—;u_WeUIIDL#�,� i0 ®0 ./.ry vft' i� ,SOQ-- �j✓vW 0Gli l , v�
5a.Well Location: Phone # 4a —a?-A '3!P�2 � � ev`�✓�' shy CX
ft 172 L
Facrlity/Ownerl3ame Fii�']D#C¢applicable) 412—ft e&
P P �-
ft fL
Physical Address,City,and zip
-.l-? 2L REMARKS
County Paine]Tdenti{cation No.(FIAT)
5b.Latitude'and longitude in degrees/mioutes/seconds or decimal degrees: P , •, eLJsaima UNIT Q,
(ifwenfield,onelatllougis sufficient) 22.Certification:
79 �3 N j�e W
qKao f-! S- q
6.Is(are)the wells): anent or ❑Temporary Signature of Certified Well Contractor Date
erm
By s/gning thisform,I hereby certlfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or a 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a copy
If thin is a repair,fdl out known well construction bformation and explain the nature of the of this record has been provided to the well owtrer
repair under i21 remarks-section or on the back of thisform. 23.Site diagram or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction mfn
construction,only 1 GPD-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarim Box).You may also attach additional pages Tf necessary.
drilled: L 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: 142-1` (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple welts list all depths tfdifferent(eramp/e-3Ua 200'and�2yA®1001
O ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information PmcessingUnit,1617 MSC,Raleigh,NC 27699-1617
lfwater level Is above casing,rcre"+"
11.Borehole diameter: 41� _(in.) Bit Off' �1 24b.For Injection Wells:Copy to 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,cto.) 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
e Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Qgr N { i
70%HTH j Oz DATE SITE VISITED:
13b.Disinfection type: Amount:
---------- -- — - VISITED BY: i
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