GW1-2022-06639_Well Construction - GW1_20220711

WELL CONSTRUCTION-REC ORD (G'V-V-1 p For Internal Use Only:
1.Well Contractor Information:
11111 ¢f4
ti $In/ . �/'t�lGa/•s� V14.WWATERZONESDPSCRIPTIONWell Contractor Nameft, IT
3v36A�NC Well Contractor CectificationNumber for mu]ti-re ed weIls ORLINER rf a licabla
YADKIN WELL COMPANY,INC. TAMMu11Eit I TffiCtss I MATERIAL
ffi in.
Company Name
/I/1 / V��11 F 16.Il`M CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: !4 W q j lti S' FROM I TO I DIAMETER I TMMgE55 I MATMAL
List all applicable well construction permits rz.m TJ7Q County,State,Variance,etc) Z ` Z it: (,�.�/g rn Q fAU
�� G<(�
3.Well Use(ebeckwell use): ft' ft. m
Water Supply Well: 17.SCREEN
FROlis TO DMML-= I SLOTSIZE tTMC1aMSS MA'r•1rurAL
❑Agricultural ❑Municipal/Public n, In.
❑Geothermal(HeatingICooling Supply) ❑Residential Water Supply(single) t ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMMT METHOD&AmouxT
Non-Water Supply Well-
onitoring ❑Recovery ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
I9.5ANDlGRAVELPACK(If a limbic)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMP1 ACEt!'I NTMETHOD
❑Aquifer Test ❑Stormwater Drainage 'ft• -
❑Experimental Technology ❑Subsidence Control ft.
❑Geothmmal(Closed Loop) ❑Tracer 20. LOG attach additionalshcetsifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under421 Remarks) FROM TO DESC=ON voter,hnrdne ,soiVrock e, sce,eta
sr s t/ J s�
4.Date Well Completed: 'L6-- L Well IDt or
�P- 0 23_ Yr ft' /ro ft s•
5aa.(Well Location- ), Phone # �'�� ft' 6 n ' So-AA
-�^/j�cl�,y � '
ft fL C� r Q EZZA �-V)
Facility/Owner Name / Facility IDA(if applicable) ft. ft
J. Q ft. ft
jut
Physical Address,City,and Zip ft ft. rr
,aLL' 21.REMARKS ..,, .�^;•;te pia i". ,�'i.-1'.,19 t�l i
IV
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification'
36 , 13131 N ® : 792oZ W -��X S= 2G -22
6.Is(are)the well(s): Nrermanent or ❑Temporary rgoatare of Certified Well Contractor Date
Bysigning thisfarm,1hereby car*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well• ❑Yes or *0 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Will Constructlan LWmdards and that a copy
1f this it a repair,fill aut known well construction information and explain the nature of the of this record has been provided to the well ownm
repair under 021 remarks section or on the back of this form.
23.Site diagram or additionalwelI 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages ff necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: 3 La o (ft.)
For multiple wells list all depths if dierent(example-3 a 200'and 2Q100D Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater Level is above casing,use"+"
f Borehole diameter 6 (in,) Bit Off: 6 e /00 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(to.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
�1
13a.Yield(gpm) �U
�nn fY Method of test: r f� Permit Program,1611 MSC,Raleigh,NC 27699-I611
�
70%HTH C1 oZ DATE SITE VISITED:
13b.Disinfection type: Amount:
nT•; r.o-
VISITED BY: