GW1-2022-08436_Well Construction - GW1_20220513

I
WELL,CONSTRUCTION RECORD (GNV-1) For Internal Use Only: k
1.Well Contractor Infornntion:
WATER ZONES
Well Contractor Name FROTf TO DESCRIPTION
1 /J ft. � ft.
O 5 7 rl ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-uaed�rells OR LINER i[a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETERS THICKNESS MATERIAL
FL
Company Name E
G, 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: W T— o d :T d FROM TO DIAMETER Tiacici SS MATERIAL
List all applicable Nell construction permits(.e,UIC,County,State,Variance,eta) ft.
? ft in.
3,Well Use(checkwell use):
17 ft' 1°'
Water Supply Well: SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public tt. ft. in!
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. inl
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT I%TETHOD&AMOUNT
Non-Water Supply Well: CIG(rQ tt, p ft. 4'I x v
❑Monitoring ft. ft
Injection Well:
ft. ft.
❑A uifer Recharge oundwater Remediation
MAY 13 2 19 SAND/GRAVEL PACK(if a licable
q
OAquifer Storage and Recovery Uinity Barrier I FROM To I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test 1t10`p1Z6pO ProceQCftAJAtrr Drainage ft• ft.
❑Experimental Technology DyVW80G0Subsidcnce Control fL ft.
geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
PC//
TO DESCRIPTION color,hardness soi0rock nin sae ate
❑Geothermal(Heating/CoolingRetum) ^ C1O01er(explain un`d1erll2l Remarks) rft.4.Date Wells)Completed3"3D• yy wellm# AAO— RE & fc5a.Weell:,ocation: Phone #.-?X- T,4 - 730( �t� tt.tl(l ft Qw' cep /�-veil •�p
`Facilityh6ner Name / Facility ID0(if applicable) ft. ft
No / /
hysical Address,City,and Zip fL ft
,t l 21.REMARKS
County /--t\ Parcel Identification No.(PIN) BORES (3) DEPTH
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( ) DIA OF LOOPS
(if we0field one laUlongissufficient) t 22.Certification: SDR OF LOOPS W )
N boo Z�, C7 ct w dz, . z_36.�'yL
6.Is(are)the well(s): Armauent or OTemporary Si a of CAfified 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 allo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Jf this is a repair,fill out known well construction tnj brmation and explain the nature of the of this record has been provided to the well owner.
repair under,#11 remarks section 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
tonstruction,onl I GW-1 ' ded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 3 4'f gnee3 24.SU13MI17AL INSTRUCTIONS
9.Total well depth below land surface: Q (ft') Submit this GW-1 within 30 days'ofll completion per thefollowin
For multiple wells list all depths if different(example-3 t©200'and 2@100) ! we com p p g=
I,
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control (AJC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction ibetbod: AIR ROTARY 24c.For Water Supply and Open-Ioop 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 DWR,CCPCUA
13a.Yield(gpm) �L Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
/! (3) '
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018