GW1-2022-07561_Well Construction - GW1_20220815

CONSTI R UC 1TION RECORD (GW-1) For Internal Use Only: �„
1.Well Contractor Infortnntion: E e D
Y®E�Se J �'✓�6a'C, /, 14.WATER ZONES I � v
C
�- FROM TO DESCRIPTION v
Well Contractor�`� " / t I Y S ft' /� fr' j ;Pt'�:vC�pMq UO .
V 3�� 3'� �" l� I . _ ; r�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER rf a Livable
YADKIN WELL COMPANY,INC. FROM Ta DIAMETER THICKNESS MATERIAL
Company Name 3 13 P ft. lb y ft 6'l;.5 in. Sb,4-01 t✓e
A loss
INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: P FZ S 1 loss ®®(2 l FROM TO DrANII:'rER I THICICMS TAXTERrAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
rROM TO DIAMETER SLOT SIZE THICKNESS MA r s uieT-
❑Aglicultural ❑ Icipal/Public f, in.
❑Geothermal(Heating/Cooling Supply) L67Residential Water Supply(single)
ft. ft.
❑Indushial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑Irrigation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENTASETHOD&.AMOUNT
Non Water Supply Well: ® it' a q ti �C , t/f,' r a�' t�... lee e
❑Monitoring ❑Recovery ft ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVF.LPACK rifa livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEWAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
10
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21=Remarks) mom
To DESCRIMON color,hardnen,so!Yrccktypt,gmlzi.izz,etr
L4yeis p vDrdA A-ele prJR S&.' t
4.Date Well(s)Completed ellID#�f3tJ""�?Ca ( gd ft CTr.�1� iris tfj/av
5a Well Location: Phone # 0Gb'd �•�.t.'k G►t 47��'k t� fv/
`God. ft. 9t g fL
_
Facility/owuerName Pacilitym#(if4plicable), ft ft
/� 16,(Z ft. ft
Physical Address,City,and Zip ft ft.
S(AVv >; 21.REMARKS 4
Con Parcel Identification No.(PIN) 6 • 3. 1 ,360 0.7
5b.Latitude and longitude in degruWminutes/seconds or decimal degrees: a 6be . 6Op' 3'�O os'-
(ifwell field,one lattlongis sufficient)' ;22. e cation: y�I 1160^ �i40 PSr
6.Ware)the well(s): dermanent or ❑Temporary a edified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PNO 15ANCAC 02C.0100 or 15AHCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction ul/brmation and erplain the nature of the of this record has beenprovided to the well UWW.
repair under#21 remarkr section or on the back qffhis form.
23.Site diagram or additional well details:
8.For Ge-oprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this'page to provide additional well construction i]3fb
construction,only 1 GW-1 needed. Indicate TOTAL NUMBER of wells (add'See Over`in Remarla Box).You may also attach additional pages if necessary.
drilled: 24.gUBM1TTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 dos of well completion per the following:
For multiple wells list all depths If different(example-30a 200'and 2®100) y p p g:
I0.5tatic water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617'IMSC,Raleigh,NC27699-1617 '
Ifwater level is above casing,use"+" ` 1
11:
Bit Off: at g go 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Borehole diameter: (in.)
Program,I636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Operi-Lbop 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 over 100.000 GPD:Copy to DWI?,CCPCUA
13a.Yield(gpm) Method of test: Y Permit Program,1611 MSC,Raleigh,3NC 27699-I6I1
13b.Disinfection type: 70%HTH �'� OZ DATE SITE VISITED: �•�- '�/ '2�
pT b VISITED BY: AZ