GW1-2022-07559_Well Construction - GW1_20220815

+Ca NSTI RUCTION RECORD(GW Or Internal Use Only: �
1.Well Contractor Inforontion:
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N / ��Vj/'T 14.WATER ZONES
Wo me FROM Wmiulti-c-asiad
NC Well Contactor Certification Number 7�S 15.OUTER RLINF.R der ficableYADKIN WELL COMPANY,INC. FROM THIC NEss :MUATERL&L
ft
Company Name
16.WIER CASING OR TUBING othermal dosed-too
2.Well Construction Permit#: 6aC 2®22®F( 't'� FROM TO DIAMLrI1tiR IEICxN ss rRTAT 5
List all applicable well construction per s(Zr-UIC,County,State,Variance eta) 7L` ft / ft /ls m. C e ^
3.Well Use(checkwell use): ft ft. in. J FyyY=333
Water Supply Well: 17.SCREEN
PROai TO DIAMETER SLOT SIZE THICKNESS MATERIAL
bicultural DMimicipal/Public ft. ft. in.
❑Geothermal(Heating/CcoIing Supply) ❑Residential Water Supply(single) g, it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
❑Irrigation ❑Wells>100,000 GPD PROM I TOI
ERIAL EMPLACEMENT METHOD all
AMOIINT
Non Water Supply Well: © ft. U
❑Monitoring ❑Recovery it ,'�Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑ Ifer Storageand Recovery �•SAND/GRAVEL PACK da lir$ble
overy ❑SalialtyBarrior FROM TO MATERIAL EMPIACLMENTMETHOD
❑Aquifer Test OStormwater Drainage ft. fit
❑Experimental Technology OSubsideace Control & it -�
❑Geothermal(Closed Loop) OTracm 20.DRILIMG LOG attach additional sheets if nececsn C
❑Geothermal(Heating/Cooling Retum) 00ther(explain under#21 Remalics) FROM TO DESCRIPTION rotor,hardness,roiVrock a sae ctc
d it g0• ft.
4.Date Well(s)Completed: 4 •12+..Well M# ' aG� �f Q.f" b"O f MO -$'d
Sa Well Location: /f Phone 42�- 'i,G-C202 ys� 7G1' °� J-099VOY era a r,o�
ft. fL
FecrlitylOwnaNam Facilil MN(if appHrable) ft ft
ft.
ft
y
Physical Address,City,and Zip ffi ft. meting U
Scaylrti 21.REMARKSa;-
County Paroel Idnntificah em No."D
5b.Latitude and longitude in degreeMulnutes/seconds or decimal degrees:
(ifwell field,one lattlongis mfficicat) 22.Certification:
3G� 24-Jiff _1v ?0"' �,C1.. .I ZF
6.Is(are)the well(s): Wermanent or ❑Tem orany ertified Well Contactor
Dace
By signing thfsfarm,l hereby cerfify that the Well(s)was(M,ere)constructed in accordance with
7.Is this a repair to an existing well: Dyes or Flo ISA NCAC 02C.0100 or 13A NCAC 01C.0200 Well Construction SYandards and that a copy
If this U a repain fd!out brown well construction information and ex plain the nature of the of0+is record has beenprovlAd to the well awner.
repair under#21 remarks secdian or on the back of thisform.
23.Site diagram or additional well 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 Remads Box).You may also attach additional pages if necessary.
drilled: 9
9.Total well depth below land surface: fL
��o—, 24.SU$1KrI-rAT•INSTRUCTIONS
For multiple wells list all depths ifdlfferent(example-3@200'and 2@1001 ( ) Submit this GW-1 within 30 days Of well completion per the following:
�� 24a. For All Wells: Original foim to Division of Water Resources (DWR),
10:Static water level below top of casing: ft. )
Ifwater level is above casing,use' d ( ) Information Processing Unif;16I7 MSC,Raleigh,NC 27699-16I7
`R Bit Off: �.9lOD 24b.For Iniection Wells: Co to
11.Borehole diameter: (in•) N DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method;
AIR ROTARY
(Le.auger,rosary,cable,direct push etc.)
24c.For Water Supply and Open=Loop Geothermal Return Wells:Copy to the
county environments]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
1 13a.Yield(gpm) Method of test: Permit Prograrn,1611 MSC,Raleigh,NC 27699-I611 1 r
Z .% T
13b.Disinfection type: 70a/e HTH Amount: �m•2 OZ DATE SITE VISITED:
2 C
P r i ce VISITED BY: nU� --I-