GW1-2022-08518_Well Construction - GW1_20220513

•'WIy)Ci H ,CON�TRUCTION RECORD(G WA) For Internal Usr.Only =�
1.Weil Contractor Informntion:
b M v`vl.) 14.WATER 20NL�N i
K15.OUT7ER
DESCRIPTION
Well Contractor N e ft.
ft
NC Well Contractor Certification Number forniulti Cal i-Yalls OltLIM de tieableYADKIN WELL COMPANY,INC. BTAKIr aRPam. _ ft m
Company Name Ycj kk^ 2Ic-�a y-^ -7Ct S f ..
16;1NiVER CASING OR TUBING eotbermal`elused too'
�. FROM ."Fi TO ., nrawrrr+•aar-,- .-TgICItNPS5 ,MATBRTAL �;_
2.Well Construction Permit#: ®t -I 213�-
List all applicable well construc[ton permi(s(i,e.UIC,COMMy,State,Yariarice etc-) ft: q` ft.fL
3.Well Use(checkwell use): ft.
Water Supply 17:5CJIEEN
pp y Well: FROM I To DMMsrrea sN ar slzNt TMCiavrass MATERIAL
❑Agricultural ❑Municipal/Public tl. ft, hi
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, fn
❑lndustda]lCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100.000 GPD FROM TO MATERTAL EMPLACNflNIt1dT WM7ff0D&AM0UN ,'f
b
Non-Water Supply Well' it ft.
❑Monitoring ❑Recovery �s f PN
Injection Well: ft ft
❑AquifearR.echarge ❑GroundwaterRemediation I9.SA1tIDfGRAVELPACK rrLfa 'livable -
❑Aquifer Storage and Recovery ❑Salinity Bmrier FROM I To MATSRTAL. ' a�NT?A=OD
❑Aquifer Test ❑StormwaterDrainage fL. fl
❑Experimental Technology ❑Subsidence Control f}• it ti i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG atta additional aLeetr if ii&&i
FROM IO DSSCRIP1I0NZ valor Lardaesr soffimrJc ate
❑Geothermal(Heating/CoolmgBetum) 00ther(explain under#21 Remsik) ft f l`
D, '(J V�• aF a
4.Date Wells Complete Well ID# 00 IfL
g ` �o?-s
5a.Well Location: Phone#3z- 'rn- 9S
/o tt� flr fl �7-
Famlity/Ownermme (/ Faci jW M#(if applicable)
If i✓ 6.-A ,A I((/1 VfL
i G Ax.t 17
Physical Address,City,and ZiP
Ya 21.REMARKS ;
Couaty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tAFtiStt3tt _
(ifwell field,one latdongis sufficient) 22.Certification:
D'WC2i60t3
3 k, 106 3 ! N
WS6.Is(are)the welI(s):.�ermanent or ❑Temporary
Of d ed Weu Contractor Dale
ily slgnfng thlsform,I hereby certify that the well(s)was(were)ccarstruciedln aceordmrce wrth-
7.Is this a repair to an existing well: CYes or W/o 15ANCAC 01C.0100 or 15A Nt di 01C.0100.*ll Constr_udian Standards and That a copy
ythis is a repair,fib out Imown well construction information and explain the narire of the of this record has been provided to the well owner
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional*ell 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 mfo
construction,only 1 OW-1 is needed" Indicate TOTAL.NUMBER of wells (add See Over'in Remarks Box).You may also attach addit<onalipages>f netxssary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) Submit this GW-1 witbin 30 days of well completion per the following
For multiple wells list all depths Ifdfjferent(erample-3@200 and 2Q1001
(ft) 24a. For All Wells: Original foim to Divlsron pf Watrr.Resouttes (DWR), "
10.Static water levtl below top of casing: Information Processing Unit,16i7 MSC,lkkt r h,°NC 27699 16I7
If water level Is above casing use ;
fs Bit Off: m 5.9�o O 24b•For Iniection Wells: Copy'to DWR,Underground Injection Control(Ii7C)
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY '
12.Well construction method: 24c.For Water Supply and Oven-Loop GeothernialReturaWeils Copyto the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing over ID0,000 GPD:Copy to DWP CCPCUA'
Penmit Program,1611 MSC;Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:_"41.1- +Of`� l
70%HTH Amount: ��•� OZ DATE SITE VISITED:
13b.Disinfection type-'
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vri r_P_r -
rmv_, mmental Quality-Division of Water Resources Revised 6-6 2018