GW1-2022-08854_Well Construction - GW1_20220912

WELL+CZNHS.IT;RIUCjTI'ON II�ECORD r!GW-1) For internal Use Only: f
1.Well Contraetor Informntion:
14.WATER ZoNLS i
Well Contractor ame FROM TO DESC ON
,�SYh o���
ft. ft.
NC Well Contractor Certification Number 15.OUTER
FRO CAO WG for muluells ORR CNZSf licable
YADKN WELL COMPANY,INC.
MATERLOLL
fr. ft. in.
Company Name
��� ��� �� I 16.INNER CASING OR TUBING eotherma]dosed-too
2.Well Construction Permit#: FROM TO DLkhTMR I TL11CIGMS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) fr• ft. U °
3,Well Use(check well use): fr. R.
C;71
17.Water Supply Welk FROM EL TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Corrmercial ❑Residential Water Supply(shared) 18.GROUT
Olrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL. EMPLACEMENTMETBOD&AMOUNT
Non Water Supply Well: ft. O tt. Uwivt 0Ucf
❑Monitoring ❑Recovery ft. ft.
Injectjon Well:
OAquifer Recharge ❑Groundwater Remedimion
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery CiSalinity Barrier FROM TO MATERIAL EAffI.ACEMENT MSIHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
Xvc6
erimental Technology ❑Subsidence Control ft. ft.
thermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM❑Geothermal(Heating/Coo]ing Retum) ❑Other(explain under#21 Remarks
TO DESCRIPTION color,hardness,soitfmck nio size,ate.
( n S ' ft. C°I L.
4.Date Well(s)Completed: ' Well ID#
5a.WellLocation: Phone # -7ft. fL
ft• fL
Facility/Owner Name Facility ID#(if applicable) ft. ft. F •)-
2022
-7 3 2 8 (�� �c>`. rye, bill, Rg L-el I �, ft. ft. -
Physical Address,City,and Zip fL ft. '',"; w sy`•::�1 M
Lr 21.REMARKS
C`
County Parce]Idcatitication No.M BORES DEPTH
Fi-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( ( ) DIA OF LOOPS( )
(ifweq field,one lat/longis sufficient) 22.Certification: SDR OF LOOPS
_ N __.----- W
Q"
6.Is(are)the well(s): w ermaneut or ❑Temporary Si re of C'' ed Well Contractor Date
By signing thisform,]hereby certify that the wells)was(were)constructed in accordance with Q
7.Is this.a repair to an existing well: ❑Yes or BNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner. C
repair under 021 remarks section or on the back offAlsform. 23.Site diagram or additional'well details: "W
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
constitt ' onIx, -1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: OE 24.SU13MMAL INSTRUCTIONS
9.Total well depth below land surface:_ 3 U Qj (n') Submit this GW-1 within 30 da s of well completion per the following:
For multiple wells list all depths if different(exampie-31n 200'and 2©100) y P P g:
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,Rale�gh,NC 27699-1617
if water level is above casing,use
11.Borehole diameter: (in.) Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control (TUC)
Program,1636 MSC,Raleigh,14C27699-1636
AIR ROTARY
12.Well construction Method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direst pusb,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
[�/ l��07�� Permit
13a.Yield(gpm) Method of test:
Program,1611 MSC,Raleigh,NC 27699 1611
7
13b.Disinfection type: 70%HTH: Amount: OZ DATE SITE VISITED:
I
VISITED BY:
pT'l C'EL r - -- - --- -
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018