GW1-2022-06623_Well Construction - GW1_20220711

1
tbmTI RUCT1 110 T RECORD (GW-Q For Internal Use Only: �
I.Well Contractor Innformn-tion:
--_✓d et!, d���as 14.1'VATERZONES (�
Well Contract Name MOM TO DESCRIPTION
®ft. ® ft, � -
NC Well Contractor Certification Number 15.OUTER CASING forniulti-rased ►f s ORLL4ER licable
YADKIN WELL COMPANY,INC.* FROM To DI&WI STER THICENESs a MATERIAL
ft. I in.
Company Name r L)- 16.INNER CASING OR TUBING(geothermal closed-loop)!
2.Well Construction Permit#:-PaWL Z®P-2 Vc®`?Q TROM TO DIAMLrTER THICIO4FSs MATERIAL j
List all applicable well construction permits(La.UIC,County,Slate,Variance,etc.) , R• ft i�s/��in. ,Y^R-a t ��
3.Well Use(check well use): ft ft. [ in.
Water Supply Well: 17.SCREEN
TROni TO DIAMETER SLOT SIZE THICIOYESS MATERIAL �/ !
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) desidential Water Supply(single) ft. ft. in.
-4
❑Industrial/Commercial ❑Residential Water Supply(shared)
1S.GROUT
❑Irrigation ❑WeIls>100,000 GPD FROM TO MATMAL EMPLACEhIENTMETHOD&AMOUNT
Non-Water Supply Well: to It
Pg: fit- he{
❑Monitoring ❑Recovery q' ft. ft. e(;g[ec�
Injection Well: ft. �
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK da ucable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMI;TSOD
❑Aquifer Test ❑Stormwater Drainage it.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILIMgGLOG attach additional sheets ifnecessa
❑Geotbennal(Heating/Cooling Rehnn) ❑Other(explain under Remarks) aROM xo DEscRmxloN cator,Coronas,soiVrocktypr,kmin size°m
d ft. 'ft S""L
4.Date Well(s)Completed: .S' I�� Well ID# '5 7 -2 &-)-ft 7coL ftiav .#
5a.Well Location: Phone ft. fL
�-
ft ft
Facility/OwnerppName Facility ID#(if applicable) ft ft. F r
ft. it R
Physical Address,City,and Zip ft ft' J U L
21.REMARKS
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CT a�
v
(ifwellfield,onelat/longis sufficient) 22.Certification: �
6.Is(are)the well(s)• 2/Permanent or ❑Temporary Siv&v cfCe6ffied Well Contractor Date
�� By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to au existing well: ❑Yes or A,.( 15A NCAC 02C.0100 or ISA NCAC 01C.0100 knell Construction Standards and that a copy
If this is a repair,fill out lmown well construction information and explain the nature of the of this record has been provided to the well owner. �1
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.For GeoprobeWT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft
For multiple wells list all depths ifdifferent(erample-3 c@200'and 1®100� ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: /1 a 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft-) Information Processing U 1617 MSC,Ralel
Ifwater level is above casing,use g gh,ItirC 27699-16I7 ��
. 11.Borehole diameter: Bit Off: 24b.For Infection Wells: Copy to DWI?,Underground Injection Control(RUC)
Program,1636 MSC,RaIeigb,NC 27699-1636
(i �
e Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return WeIIs Copy to the
.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS 0 Yz W- 24d.For Water WeIIs producing over 100,000 GPD: Ca to D
1 " Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy
CCPCUA
13a.Yield(gpm) �' a Method of test: •�
13b.Disinfection type:
70%HTH
Amoun y� OZ DATE SITE VISITEDa Z-` �
Pry! VISITED BY: �