GW1-2022-08533_Well Construction - GW1_20220408

$,�tC�31�T�1J1�1UC7CT(�I�L 'C�1D� �F1-1� For Internal Use Only:
1.Well Contra for^Information:
0. 1 ( 14.WATER ZONES i
Well Contractor Name FROM I TO DESCRIPTION
c(�` ft
3 85-
[ ft.
U ,?— Q 1 ft, v ft,
NC Well Contractor Cutificaticn Number
IS.OUTER CASING for multi-cased wells ORLWF.R rf a linM&TxRAL
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICEINESs R ia.CompanyName ^ 16.1"ER CASING OR TUBING eothermal closed-loo2.Well Construction Permit#: VV Q 0'ua� oM xo DIAM rrrn TRICKMS
List all applicable well construction permits(ie Mr,County,State,Variance,etc) ft R rn
3.Well Use(check well use): ft. ft• 'n
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKMSS� MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) X6sidential Water Supply(single) ft. ft. in.
❑Iudustrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM -TO MATERIAI. j EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' ft., I. S V vo—e l C7'
❑Monitoring ❑Recovery ft ft �+✓l�n 'f C �l f�/ u Id
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation Iy SANDIGRAVEL PACK rif appIl6bie)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL E111:PLACEMENTML'THOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRM11NG LOG attach additional sheetsifnecessn
❑Geothermal(Heating/Cooling Rehm.) ❑Other(explain under#21 Remadcs) FROM xo DFseRrPxtoN cuter,n,rdaess,soUrnrk a see eta
fir' tL f ft. r
4.Date Well(s)Completed .��� a WeII ID# U��� g ft. sPY M 4uol
5a Well LDcstiDn: Phone # Pol-1-0-52(52 ft
•r--, �rm s, ��9 ft ft -
Fac�il4to/wnerName / FacilityM#(if applicable) ft
Physical Address,City,an' ?aP ft ft
Z1.REMARKS
Coca = i Parcel Man lrEcation No.(PIIl)5b.Latitude and Iongltude in degrees/minutes/seconds or decimal degrees:
gwell field,one limongid itiffcient) 22.Certification:
3G N _S�o 3z17.S ? W
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Conractof' Data
By signing thisform,I hereby cen fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction,Standards and That a copy
If this is a repair,fdl out'known well construction information Admplain the nature of the of this record has been provided to the w'ell owner.
repair render#21 remarkr section or on the back of this form..
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 mfo
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Da` (ft.)
For multiple wells list all depths 11f fjeteat(ermnple-3@200'and 2®100� Submit this GW-1 within 30 days;of well completion per the following:
S0 24s. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water leve)below top of casing: (ft-) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use ^^
11t'Borehole diameter (in.) Bit Off: . d 24b.For Injection Wells: Copy t6-;DWR,Underground Injection Control(IUC)
Programs,1636 MSC,Raleigh,NC"27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open=hoop 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
C Permit Program,1611,,,MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: qAf - i
13b.Disinfection type: 70%HTH Amount; OZ DATE SITE VISITED. 3-7J =NV� 9^3
614 V5
Pri rP- 4M VISITED BY: -3A4