GW1-2022-06647_Well Construction - GW1_20220711

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WELL CONSTRUCTION RECORD [GW-1 a For Intemal Use Only:
1.Well Contractor lnfornntion:
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ESCRIPTION
Well Contactor Name y
3 0 3 6 I 3�.j^'
NC Well Contactor Certification Numberlfi-rssed!wells ORLINER ifa linableYADKIN WELL COMPANY,INC. DIAMETER' TffiCRl]E65 MATERIAL
CompaayName �9 g f 16.INNER CASING OILTU13ING eo mal closed-loo )
p V 2.Well Construction Permit#: M `7 0 13 I. •� FROM TO DIAMETER TfficrINrss I WIATGRIAL
List all applicable N+cll construction permits(i,e,i7IC,County,State,Variance,eta.) .2 ft 7Z ft b SA 'n Q 1n' GS 1%, {
3,Well Use("beck well use): ft' ft• 'n
Water Supply Well: 27•SCREEN
P
TO DIAMETER' SLOT SIZE TJUOQC,SS MATERIAL
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, it,,
❑Industdal/Commercial ❑Residential Water Supply(shared) T
❑Irrigation ❑Wells>100,000 GPD TO MATERIAL EMPLACEMENT]%MTHOD&AMOUNT
9Water Supply Well: 0 ft. �0 ft.
Monitoring ❑Recovery ft. ft.
Injection Well:
ff. ff.
❑Aquifer Recharge ❑Groundwater Remediation
19,SANDIGRAVEL PACK(if a linable)
❑Aquifer Storage and Recovery ❑SallnityBarrier FROM TO MATERIAL - EUPUCLMMNT1v=oD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Rettnn) ❑Other(explain under#21 Remarks) K� :
To DESCRIPTION color,bnrdness,suivrodc sae,etc.n �qp4.Date Well(s)Completed:S' Z1-ZZWll DmAAt'® Vd L J- ft•5a.WellLocation: Phone # �.� ft. S '
m 6 S G2,�r�. 44 W - ©G 6X ft 190 'L �4 s Ic 6,,yr+,e—
Famlity/OwnerName Facility ID#(ifapplicable) ft. ft.
,tom"
L 2� ff. ft �. r.
Physical Address,City,and Zip �— ft. ff.
I/ ;•� 21.REALU C
County (`` Parcel Identification No.(PIN) 1t•'.n� .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,One lat/longis sufficient) 22.Certification:
f `� �71 �G7 `t N 86" `��7� qq W � -r-25- 1 2
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
[` By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LINo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Will Construction Standards and that a copy
If this is a repair,fill out known well construction irilbrmatlan and erplain the nature of the of this record has been provided to the Nell owner.
repair under.#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.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 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: -/U Lo (fL)
For multiple wells list all depths if diereni(example-3(a)200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
��i ft. 24a' For All Wells: Original foim',to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)
) Information Processing Undt,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter (in•) Bit Off: 4 ,09 24b.For Injection Wells: Copy t6 DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open=L6op 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 oyl r 100,000 GPD:Copy to DWR,CCPCUA
nn Permit Program,1611 MSC,Raleigh,i C 27699-1611
13a.Yield(gpm) o� Method of test: A '
OZ DATE SITE VISITED:
13b.Disinfection type: 70%HTH Amount: �-�
Pri
VISITED BY:
1-e-