GW1-2022-08225_Well Construction - GW1_20220513

i
�4 +CaNS TRNCTION RECORD(GW-11) For Internal Use Only: i
I.Well Contractor InTornA'atiolln:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION '
�Li5. it. 3Wft 2 G Pun
NC Well Contractor Certification Number
15.OUTER CASING formulti-rased wells ORLINER if a livable
YADKIN WELL COMPANY,ING. FROM To DIAMETER TSIC XNESS MATERIAL
ft it. in.
Company Name I I '
/ G�{� 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: TO( FROM DIAMETER T8ICCNESB !MATERIAL ^�
List all applicable well construction permits fl e.UIC,County,State,Variance,etc) ¢ J ® �3f in. `� �G l�• fi
3.Well Use(check well use): ft' 1II'
Water Supply Well: mom
SCREEN
FROM TO DIAMETER SLOTSIZE T1IC1QWSS MATERGIL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in. (,
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATBALU. EMPLACEMINT METHOD&AMOUNT�a .:z�
Non-Water Supply Well: ft. 5 ft. t k P� `w �, "rsI
❑Monitoring ❑Recovery
Injection Well: it aft 5 � Q vir&eui
ft. fL a
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rifa lirable h
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To, MATERIAL EMPLACEMENTMETSOD
[]Aquifer Test ❑Stormwater Drainage' ft R
❑Experimental Technology ❑Subsidence Cool ft iL - : "
❑Geothermal(Closed Loop) ❑Tracer 29.DRILL?rIG LOG attach additional sheets if nec�sa � ►
❑Geothermal(Heating/Cooling Rehnn) 00ther(explain under#21 Remarks) aROM TO DESCRIPTION.ml°r,hardaess;'s`mVmctc' -T 1!x itr`•
O ft. (QS � 1+6e
4.Date Wells)Completed: L �i7 J.)WellID '�'~ L f•OS '* 6yU•h • r
I 5a.well Location ` Phone # ( -�1•(r
ft fL
Facility/Owner-Name FacililyID#(ifgvlicamr) ft it ?,
x � C
MAY 1
Physical Address,City,and Zip ft ft
21.PLYKARTCR ► i 1,
County Pmreel Identification No.(FIDE)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: X
(ifwell field,one lat/loagis sufficient) 22.Certification:
h�
6.Is(are)the well(s): &ermanent or ❑Temporary SignaJare ofC • ed Well Contractor i Date
fyp>
By signing thisfarnt,l hereby ctrtj fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an erdsting well: ❑Yes or IWO 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stmrdardsrm d lhct a,copy
IfthLs is a repair,fdl out known well constructlan information 047erplaih the nature of the of this retard has beenprovided tothe well Owner.
repafrunder#21 remarks section or on the back ofthisform.
23,Site diagram or additionalwell details:
8'For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional}yell construction info
(add'See Or'in Remarim Box).You may also attach additional pages if
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells ve recess '
drilled: jJ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( )
For multiple wells list aJl depths t different exam Te-3 00 m d 2? ft Submit this GW-1 within 30 days of well completion per the following:
P P f ( P Oa Z ® ,0i I l�
24a. For All Wells: Original form to Division of.Vlater Resources (DWR) r
1D.5tatfc water level below top of casing: � A-) information Processing Unit,1611,MSC,RaIet NC 27699 16I
Ifrvater level Is above rosin use '
` & Bit Off'. 24b.For In-iection Wells: Co to D & ^`Copy• WR Undergroirnd Injec�aon
11.Borehole diameter: (in.) x
•. Program,1636 MSC,Raleigh,NG27699-1636
12.Well construction method: AIR ROTARYa i 1
24c.For Water Supply and Open-Loop Geothermal Return,Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc)
'^ ..c, coimty environmental health department of the county where,installed
FOR WATER SUPPLY WELLS ONLY: 24d.For.WaterWellsproducing yer100000;GPD:Copy"toiDWR,,CCPCUA;
Ll
l 4 Permityrogram,1611 MSC,Raleigh;NC 27699-16141 ;
13a.Yield(gpm)
Method of#esf
70%HTH r> DATE SITE VISITED:
13b.Disinfection type: `'Amount E T �U
RNAyr
VISITED B