GW1-2022-06610_Well Construction - GW1_20220711

'b'y L , ^pNSTR1tJC ITION RECORD (GW- ) For Internal Use Only:
1.Well ContralUNnformation: -
go -14-17 iW •Sc()lAipi 14.WATER ZONES I '
Well Contractor Name FROM TO DESCRIPTION
*63ft 3 '--(cam
3 o 3 4 4 .R7 it. �sx ft. ( T
NC Well Contractor Certification Number 15.OUTER CARING(for niu]ii-a ed wells)ORLINER(if ap licable)
YADKIN WELL COMPANY,INC. _FROM To :DIAMETER T7 ESS MATE
ft
Company Name 16.INNER CASING OR TUBING(geothermal dosed loop) •
2.Well Construction Permit#: P Q , PROM , TO _DIAMETER TRCENESS MATERIAL
List all applicable well construction permits(Le.UIC,County,Slate,Variance,etc) f f ft t I a ft 6_ /./ I\y in• SD d1 _oC rl) P.G
3.Well Use(check well use): ft ft. ( in. { /
N
Water Supply Well: FRO37. M
TO DIAMETER SLOT SIZE THICICNESS MATERIAL 1
❑Agricultural Olvlu,icipallPublio it. , in. --- J '
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. in. C
•
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
Obligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft 3 ft. Ry,Au,Att 4"4 (; t 3
:Monitoring :Recovery aq•
it .Z ft �>a�itfe .��i. / y©L 1
Injection Well: ft ft. �° � ,
' oAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑SalmityBarrier FROM TO MATERIAL EMPLACEMENT METHOD 1
❑Aquifer Test ❑Stormwater Drainage ft. ft ti
❑Experimental Technology ❑Subsidence Control ft ft
0 Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(colon hardness,son/rock type Siva Sur etc)
® ft. 3.1" ft So r`
/ /�A ft. ft. �e ,
4.Date Well(s)Completed: 6'•3' L Z. Well#,f?f9 02 7 3,f ,�63 {y��, `-`� ,�
y O'N. 3 3 f 3s it �� - .t��
Sa.Well Location Phone # 1 ®, c4 32V2. Z,'D e4
� �e'�eJ 6 �Nd.� 34k ft 33'2 ft iite,..e 6.,e,,,fie,
dFi°,�geIQ.�
Facility/OwnerName'it �s°6. a gt9'N /J Facility ID#(if applicable) ft. ft.
Physical Address,City,and//np Zip ft ft. JUL7
CetC did e d' 22.REMARKS L J..i 71127
County Parcel Identification No.(REN) [r&4i ZiC;l.10sM
lt::.'3('+�'iff.' til R3 C c+nrn u
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �.. tTIC;.�i��., .rd.,uv Li<{
(if well field,one let/long is sufficient) 22.Certification: •
36 alI, et,ro N gr .ST-0 W s y_
6.Is(are)the well(s): tatcmanent or OTemporary Signature of Certified Well Contractor Date
�`,� By signing thisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l io 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided,to the well owner.
repair under#21 remarks section or on the back ofthisform.
23.Site diagram or additional well details:
8.For GeoprobetDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constriction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
chilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 k'e2 (ft.)
For multiple wells list all depths If-different(example-3Qa 200'and 2(4100� Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original fora to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
a Ifwaler level Is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: S 9/Z 24b.For Injection Wells:;Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
I
12.WeIl construction method: AIR ROTARY I
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 producing over 100,000 GPD: Copy to DWR,CCPCUA
\ Permit Program,1611 MSC,Raleigh,NC 27699-I611
V 13a.Yield(gpm) !U Method of test: ri y C1,t,
70%HTH /]>e OZ DATE SITE VISITED: I
13b.Disinfection type: Amount oC to
I_. _ _ _... .__.., __ __. _.__ -- _ VIRrrmri my. A.l' '