GW1-2022-06602_Well Construction - GW1_20220711

JT1Z�1i RECORD(G'VV-1) For Internal Use Only: I
1.Well contractor Information:
_ mom' ��A<d W,"7 14.WATERZONE'S
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number '2® �
I5.OUTER CA.SIl�TG forriiulti-cased wells ORLINER if a livable
YADKIN WELL COMPANY,INC. FRoh1 Ta DIAML�TER THICKNESS MATERL\L
eft- ft. m.
Company Namc
16.INNER CASING ORTUBING( eothermal dosed-loo ®,
2.Well Construction Permit#: � r l eq r YA FROM To DIA1prL'TER THIctaim- S MATERIAL
List all applicable well constructlon permits fl.e.UIC,County,Slate,Variance,etc) -- ft in. v
3.Well Use(checkwell use): R' ft. 1n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TEICIDUSS MATERUL
❑Agricultural ❑Municipai/Public ft. .ft: in. "
❑Geothermal(Heating/Cooling Supply) 9esidential Water Supply(single) �f, ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>I00,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. ft. C �� IP
❑Monitoring DR.ecovery 3 it. ffi
TnjectionWell: &"i,
It.
❑Aquifer Recharge ❑Groundwater R.emediation
❑ ulferSto Storage ❑SaIini gamer 39.SAND/GRAVEL PACK a lirable)
AQ r ty FROM TO--- MATERIAL EMPLACCMENTMETHOD ®�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 60, ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIlVGLOG attach additional sheets ifnecessary)
❑Geothermal(Heaiing/CoolingReturn) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,fi°rdnrss,s°ivrock a aia sae etc
tq- Lfty- � � 9 v ft. ft. Ste.i
4.Date Well(s)Completed: /�p�Z WellD## 0- ft. 'el 7ft Co A Alley v"a C/
5a.Well Location: Phone # gm- 4 ft ft' �• ,!�
. Ao �`�� f �o ft ft
Facility/OwnerName dp� Facility ID#(lfapplicable) ft ft.
/J4, 4d (I[(1 10 1� ft ft Q a
Physical Address,City,and Zip ft ft. c LIP
o zx.REMARKS
County , Parcel Identification No.(PIN) s :% e" r7 l r11 1G t r*'�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: m W
om
(ifwell field,one lat/longis sufficient) 22.Certification: 7,"W I t' M GES8gNG UNIT
1,-7e C. 2- lv �d� .��� � �� w � ��
6.Is(Rre)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
� By signingthisfonn,I hereby certify chat the wells)was(were)constructed in accordance with
4r'C 7.is this a repair to an existing well: Dyes or ISANCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fdl ouf known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under i21 remarks section or an the back of this form.
23.5ite 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 infu
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remaft Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMTITAL IKSTRUCTIONS �•^
9.Total well depth below land surface: 2
For multiple wells list all depths ifdPrent(example-3(a)200'and2©1001 Submit this GWA within 30 days of well completion per the following:
f 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: / (ft) IDformation processing UrA 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use'+' A 11 Borehole diameter (�) Bit Offt /.azs� 24b.For Injection Wells: Copy'to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NC 27699-1636
AIR ROTARY
12.Well construction methad: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.sugar.rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Pmgram,1611 MSC,Raleigh,NC 27699-16I1
13a.Yield(gpm) GX 0 Method of test: wer
° DATE SITE VISITED: m 13b.Disinfection type: 70�°H f}I Amount: OZWei
Pry c- ' VISITED BY: _a try