GW1-2022-06622_Well Construction - GW1_20220711

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Well Contractor Name FF.Ot•1 O DZSCLDTIC-H
3,0 3 �s z ft. 83 ;1- 1( J-6 -2
ft. no
it _ y
i4C Well Contractor Certification Number 15ix
. R Ca�IPTG formulfi cas'ed;welfs OR LIIdER if a licable ►��
YADKIN WELL COMPANY,INC. FROM To DLUMTER -THIQQVE55NATERUL l q
ft. in
CampanyName 16,INNER CASING OR TUBING( atherma!closed-log )
2.Well Construction Permit#: t� �.®� ®�`•r g� FROM To I DJAPMTER I IMCUNESS MATE'RrnL ® r
List all applicable well constructlon permits(Le.UIC,County,State,Variance,etc) It• ft. L in. /I s �f e A-1
3.Well Use(check well use): ft. ft. in. ./
Water Supply,%cell: 17.SCP�, i i
"Rord TD DI?_MEMER SLOTSIii TO-,r!4TrrSG I a1-iiPi
❑Agricultural ❑Municipal/Public it. ft, ire.
❑Geothermal(Heating/Cooling Supply) Pj'iesidentia!Water Supply(single) it ia�
'r
❑lndustriaUCommercial ❑Residential Water Supply(shared) ]d•GROUT
❑Irrigation ❑Wells>100,000 GPD MON TO hLMRIAL FAIIPLACEnrNT PIE T50D a A1.100NT �
Non-Water Supply Well: ii, ft . y11 3
❑Monitoring ❑Recovery fed `r PIS -
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SA1101GBAVEL PACK(if applicable) �V 9
❑Aquifer Storage and Recovery ❑Salinity Barrier F ON TO _ PdAIT AL LAM. hMMLOD
❑Aquifer Test ❑Stormwater Drainage ft. o"
❑Experimental Technology OSubsidence Control ft -�
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach addifidunfisheatsifirecessan,1
❑Geothermal(II•eating/Cooling Retnm) ❑Other(explain under 421 Remarks) I1R0a2 To DESCRIPTION(color,bardnar,saigraelc type,grain sae.eta
9 y ® ft. -7d f�
G4.Date Well(s)Completed: n I ZZ Well ED# —4 04; R• L]� ft.
Sa Well Location: Phone # 1'3 4�� ft
v ,%Po �./s 4 2—amr-3f Fg-iV
Facility/Owner Name Facility ID#(ifapplicable) ft. ft• _ IT
3 M EC D
Physical Address,City,and Zip ft. ft. JUL
�+ 21.RXrdARKS
County Parcel Identification No.(PIN) p y\S, LTti)i�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lrrL� ,iaTiu1�i �CC��I�� ► I
(f well field,one latAong is sufficient)
.� 22.Certification:
6.Is(are)the well(s):APermanent or ❑Temporary Bigaatute of Certified Well Contractor Dan
By sfgnbig thisform,I hereby certify that the wells)war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or xqo 15ANCAC 02C.0100 or 15A 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 remarkrsection or on the barkofthisform. 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 provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMB)Rt of wells (add'See Over'in Remarks Box).You may also aticch additional pages if necessary.
drilled: ] 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: L�(V?_'Formulitple wells list all depths fdlfferent(mample-3@200'and2(a)100) (ft) Submit this GW-1 within 30 daysl ofwell completion per the following:
(,10.5tatic water IeveI below tap of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.
Ifwater level is above casing,use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1I.Borehole diameter: (in.) MOM 46,1i,2 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
;a Program,1636 MSC,Raleigh,NC 27699-I636
12,Well construction method: AIR ROTARY 24c.For Water Supply and Open(L j
oop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct pitch,etc.) county environmental health departinent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing I over 100.000 GPD• Copy to DWR,CCPCUA
Q
13a.Yield(gpm) EJ 1) Method of test: 0 Permit Program,1611 MSC,Raleigh,NC 27699-1 111 �P
13b.Disinfection type: 70%HTH Amount: 30 OZ DATE SITE VISITED:- ✓®Z� �' iv-
s
VISITED BY: (/1 A A q
Faun GW-1 uienta]Quality-Division of Water Itesouroes Revised 6-6-201 S