GW1-2022-06636_Well Construction - GW1_20220711

.=;�;tl��bNS1' 'Z(CTION 1'CORD QW-11 For Internal Use Only: f
1.Wch Contractor Informnti n:
r ' l.�M7S 14.WATER ZONES j
Well Contractor ame FROM TO TION
A ft, ft
NC We Contractor Certification Number IS.OUTER CASING formulti-cased•weus ORLTNER ifa tirable
YADKIN WELL COMPANY,INC. FROM TO DUMETER THICE01ESs MATERUL
ft. ft in.
Company Name I J 3 � e q,6 3r 16.INNER CASING OR TUBING eothermal rlosed400 qj
6p
2.Well Construction Permit#: w 3 P AA 0 f 4 X6-2- 2-0 i FROM TO DIAMETRR I THICKNESS I ?kqr, IAL t
List all applicable well construction peyw its(Le.EUr,County,State,Yarlalnce,etc) / R• 9_7 ft ,O-S'ru• SD _4� P Vc- ^�
3.Well Use(checkwell use): fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICIOYESS MATERIAL
❑Agricultural ❑M icipal/Public ft. ft. in. - - q,
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft, ft.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AWO NT
Non-Water Supply Well: ft R -66; BUP�
❑Monitoring ❑Recovery ft. , ft 1 . e�
Injection Well: ft R
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a llcable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EMPLACEMRNTld=, OD
❑Aquifer Test ❑Stormwater Drainage ft.❑Experimental Technology ❑Subsidence Control ft it:
❑Geothermal(Closed Loop) ❑Tracer 1 20•DRILLINGLOG attach additional sheets ifnecessary)
❑Geothermal(Heating/CoclingRetum) ❑Other(explain under#F21 Remarks66) FROM To DMSCRIPTION color,hardness•so!Yrock a sae,etc�� ® ft. 7Z� ft- _56
4.Date Well(s)Completed: " WeH Mff ^' A 0 51�" 70
b c P
5a.Well Location; Phone #-!3(, y ( fL ft.
ft ft
�C ram'
Facility/OwnerName 1 FacilityM9(if applicable) fL fL F-1 ?Mo
Physical Address,dy,and Zip ft . it JUL 022
r '
V4z A K!e� 2x.REMARKS
Com* ri Paroel Identification No.(PIN) FFRO�PPFSU .n,, -
5b.Latitude and longitude in degreeshidnutes/seconds or decimal degrees:
(ifwell field,one lattlongis sufficient) 22.Certification:
N Jr.
9 6. 22-
6.Is(are)the well(s): 'ermanent or ❑Temporary atnre of ed Well Contract c6,or Date
By signing thisfa m,I hereby certj/y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or "n< lSA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Imown well construction btfarmation and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Gecprobe1DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction infD
construction,only 1 GW-1 is reded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box),You may also attach additional pages if necessary.
drilled: [/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) Submit this GW-i within 30 days of well completion per the following:
For multiple wells list all depths 1fd{fferent(emmple-3©100'and2@100c) y P P
10.Staticwater Ievel below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Process
ingUnit,16171`ASC'Raleigh,NC 27699-1617 '
lfwater level Is above casing,use"+"
1PBorehole diameter: Bit Off: • 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-hoop Geothermal Return Wells:Copy to the
(ie,auger.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
11 PermitProgrann 1611 MSC,Raleigh,INC27699-1611
13a.Yield(gpm) Method of test: a� e1TEi7z—
J
13b.Disinfection type: 70%HTH Amount ! ,i c 2 DATE SITE VISITED: 7 '7'I i ®�
Teri
VISITED BY: !�