GW1-2022-08733_Well Construction - GW1_20220408

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�Cd�1�T$TeZtJCT1I+®l�T 1T8 �CO f1a�d'-1) ry�For Internal Use Only: °< l;
1,wen contractor information:
14 1'VATER20PILr6 A
Well Contractor sine FROA4. TO DESCRIPTIONx y
k s�
a3 vtr. 232ft �. ac-l'vre40 . o�k
WC Wall Contractor Certification Number k:15.OUTER CASING for multi-&sadveLls`:ORILINER'�f a licabl�
YADKIN WELL COMPANY,INC. aFROM TO' '" 31A -= "4TffiC[ MS IMATl =R Illl
x 'ft.f xin. :m
Company Name
16 IIVIVER CASING OR TUBING.'°thermal ielcYsed'--too
2.Well Construction Permit#: S3 i FROM r` TO :'. �rDrAI�RER THICIQVFSB rMwTERrAitr■�■rt
List all applicable well construction permits(e.In;-County,State,Variance,eta.J '; it
3.Well Use(check well use): „
17:4SCREEN h
Water Supply Wellw r 4f 1swrISIZE�1<TffiGItS1ES51i)EMiCCERtA.�
4TRQM TO �Z <Dr�nfwrFR
❑Agricultural ❑Muniaipal/Public iti;
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single), ,' R�tt
❑Indusrrial/Commercial pResidenfial Water Supply(ihared) 113�(GROUT
❑Irrigation ❑Wells>100,000 GPD ;uFROM Toy IfMATERIAL 1�E1 r7�►CEM MI, nQ,Tooay���nsomyTA
Non-Water Supply Well:
❑Monitoring .j ; {,j ❑Iteoopery.
bjection WdE _..
❑Aquifergeaharg,APR 09 Z�Z- ❑GroundwaterRemediation
19.�SANDJGRAVELI CLCi da IiF3jT le
❑Aquifer Storage and Recavery ❑Salinity Barrier I+Ron2r a xo inteTEx7AI. fE1 7:ACEML+NTII�THOD�r
❑Aquifer Test f 1 n i G1Stoimwater Drainage
❑Experimental 1�chnolbgy}? oSubsidence Control ffi. it
❑Geothermal(Closed Loop) OTracer 20,DRIL:LIlVGSLrUG?atlaeh�additionaltahee"fs fineeBsa
o FROM PTO )DESCRiP1IW c°ler0liarr
❑Geothermal(Heating/Coolmg Retiun) OOther(explain tinder#21 Rbma:dcs):
4.Date Wells Completed:. WeIIID# .'� a`�W-a-`�
Sa.Well Location: Phone # 3 61A W's��` 1
• � a�� Gyt�,u�rr _� r '
Facility/OwnerName FacililylD#(rf�epphcable):` ft tt
Physical Address, and City Tap �' a .IL
+ � r�i k r �r
/ n I21RTr1CTARKR
iAJ
r x `� "� CO1/'tr'L°a;rye� ;,u; � Q� �i'vrav-�- , �-0✓
courdy EaroelIdcat�cah nNo$
5b.Latitude and longitude]n degrees/miniites/seconds or decimal degrees ;
(ifwell field,one lat/loag is sufficient)' _ZZ Cerlifieation:
•� Sr a of ' Well°tsonfi�actor Date
6.D(are)the weU(s): permanent or []Temporary h
Byslgnmg if or
thewefl(s)was(wereJc fn,accardancew'
7.is this a repair to an extstrng well: , ❑Yes or j Io ISANC 4C 01C D1'On pr/3i1 KGAC 01C.0100 Well Constnrdion 1m+dardr mid►hat.a copy
afihts ieeoirihas beenprovided to,the elf owner.
If this is a repair,fill out known well l construction information and rsploin the nature ofthe
repair under dill remarks section or an the back bfthis foam: �
23 5tte diagram or ad ditionalwelt.detaila:
8.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You mayuse the back oftlpage W provide additional well construction,iufn
construction,only 1 OW-1 is needed Indicate TOTALNUMBER of wells (add See Over'm Remads:Box).You,may also attach additional pages ifaecessary.
drilled: y 24 SUBNiTITALINSTRUCTIUNS
9.Total well depth below land surface: A)a�Su6mit thfe GV{'-1 mth n:3D,days.of� ail completfon per the fo lowing:.
For multiple walk list s/l depths/fdijjeient(example-3Q200'and l®700) � � r
dv K
24a :For�A1L- Ls:,Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: lo0 (fh) Informahon Pmcessmg Unrt,1617MSC.Raleigh,NC 27699-L61i7
Ifwater level is above casing,use �
Sit Off 24b:Foe.,]niectionWells: Copyto DWR,Underground Injection Con (1lJC)
11,Borehole diameter: (in.) Piogram,1636 MSC illigh,NC>27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply,andDpen I.00pGeothe, al Return R'ells:Copy to#he
(i.e.auger rotary;cable,dirzct push etc.). comity envnonrriemal health departaierit?of the county where iir`stalled
ep
FOR WATER SUPPLY WELLS ONLY: 24d.For-WateipYells'pi•oducinryer 100,000 GPD:Copy to DWR,GGPCUA
Permit Program41611 MSC Raleigh+NC 2Z699a16s11
13a.Yield(gpm) Method oftes_t: QrtY � �
70°�HTH DATE SITE VISITED:
13b.Disinfection type: Amount: i
w VISITED BY: