GW1-2022-07227_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor information:
MI L(1144J C13 W01 14.WATER ZONES
I - FROM TO DESCRIPTION
Well Contractor Name
/to , 1/1 1 .3 e..?- 36
ft.
5-
NC Well Contractor Certification Numbs is,OUTER CASING ffor!��%Zked L if ap9licable)
7' FROM A MATE&LAL
YADKJN WELL COMPANY,INC.
Company Name APR 0 8
IrDMM CASING OR TUBING( eothetmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETERI THICIams NTA71
List all applicable well construction permils(71--m=,'CointY,State.V�1�io cy in.
3.Well Use(checkwell use). ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER
I SLOT SIZE TMCIMSS MATERIAL
N691cultural OMunicipal/Publio ft
DGeothmmal(Heating/Cooling Supply) DResidential Water Supply(single) ft.
Elladustrial/Commercial DRzsidential Water Supply(shared) 18.GROUT
OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT AMTHOD&AMOUNT
Non-Water Supply Well: f'- 3 ft-
OMonibring ORecovery ft
Injection Well:
ft ft.
OAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(ifapnUmble)
OAquifer Storage and Recovery 0 S alinity Barrier FROM TO WATERML EXPLACIEWNTDIMOD
DAquifer Test DStoTmwater Drainage ft. fL
DExperimental Technology OSubsidence Control ft ft.
DGeotheImal(Closed Loop) oTracer 20.DRHJJNGLOG(att2c essary)
-
FROM TO DESCRIPTION
(color,hardus,soin/mcktype,grdw sae,eh.
t 00cothermal(Heating/CoolingReturn) 00ther(explain under#21 Remarks)
m
0 ft. ft. 40 al.,
.3-3o-22- C/
Well H)#A&-I a 3
4.Date Well(s)Completed f" 36 'L .4o ex&
'76 Sa.;A
Zft
Sa.Well Location- Phone kyJTC- 1/0'7-1,r4L-3 (V ft ZI .
tv, Filrw% f Oa AM-Aa
M on Na
me �(a - - Facility IDA Cif applicable) ft V zro k
k;114
-'W9.d Address,City,and Zip 1) ft. ft.
21.PLEATARTO
Ae" 'oa A.,
county Parcel Identification No.UT4) ors j
-4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
-lei k N Xq W
3
6.Is(are)the well(s): ofermanent or OTemporary Signature of Certified Well Con' actor Date
By signing thirfarm,]hereby certify that the wells)was(were)constructed in accordance with
o M*
7.Is this a repair to an existing well: Dyes or 15ANCACO2C.0100orl5ANCACO2C.0200 3Fell Construction Standards and that a copy
If this isa repair,fill out known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section or an the back of this form. 23.Site diagram or additional Well details-
You may use the back of this page to provide additional well construction info
Closed-Loop Geothermal' having the same
8.For Geoprobe/DPT or C1 (add See Over'in Remarks Box).You may also attach additional pages if necessary.
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled,- 24.SUBNE[TTAL INSTRUCTIONS
depth below land surface:
9.Total well dep Submit this GW­1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: -7L-' -(ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level Is above casing,use Bit Off. Underground Injection Control (lUC)
24b.For Injection Wells: Copy to DWR.
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open!Loop Geothermal Return Wells:Copy to the
(Lt.auger.rotary,wibla.direct P-b,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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp-) /6 Method of test: A//,
70%HTH a 0z DATE SITE VISITED: f 2-tee
13b.Disinfectiori type-- Amount: -
... . .... ..
VISITED i B
000404WA i i ,l ,