GW1-2022-08918_Well Construction - GW1_20220912

t 1 J,# as_.._.
ALL rC�I�TS 1 1 �+D�1�I: iC� ➢rdr�-�) For Internal Use Only:
I. ell Contractor nformation
41 w
4 7. 14.1'VATER 2,ONL+3 1 I
FRUT4, TO DMCRIPTION
Vi►e11 Conlract� eme�� r•> {A i1 ft
NC Well Contactor Certifi'eat�Nnmber mi.OITr=CASWG fornuulli-cased ORLDVER if a Gcable
YADKIN WELL COMPANY,INC FROM TO DIAMETER TffiC[QVFSs MATERIAL
it ft. in C
�r
CompanyName y 16.DUM CARING OR TUBING thermal closedaoo CJ
2.well Construction Permit# ,� FROM TO DIAMETER TMCJCJBSs MATERIAL �-
sr dll applicable w`eYl ronstruc!n'perm'irs 4e L►IG County,Sidi;,Variance,C4 ft a 2 In.
We11 Use(checkwell use): �� � ft ;n,
M
water s�—ly well. . j Y ».scREsrr f
PP» t e FROM TO I DI I SLOT slzE I THICIOYESS I MATERIAL
OAgacultnraI „OMunicipaUPublio ft. ft. in.
OGt othecrosl(Heating�CoolingtSupp y� ) Idenhal Water Supply(single) ft, n. in,
OIn C•ornntercial c C*]Resrdeithal Water Supply(shared) lti.GROUT
�t
t�IIII On r wC11S>IDD;600 Gz D FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
1?44 .,f i/l /L-re
a;❑Recove y'. Ltf° a t1 f K ns
In"ectioD We1L• � ? �
Groundwater Remediation
❑AtlurferRecharge k 1 r;1. c 19.SANDIGRAVEL PACK da licable
in'jLT StOrRge end�Recovery.` �' a�tnnier FROM TO I MATERW. EMPLACEMENT METHOD
OAquifier Test 4. t� water Drainage
�Fxperim:mte]Technology .❑Subsidence Control fa it.
l7Geothermal(Closed Lapp) ®Tracer 20:DRMLINGLOG attach additional sheets if nemsa
FFROMI TO DESCRIPTION color,hardness,xoi-Vrucklyp4lzrnin sirs,etc.
Ot3eothermal + esting/_CoolmgRatmnj ❑Other,(explam.under#21 RemadcsIL
ppv �6
4.Date weD(s)Cnmpletea: d' �- welI 7D#„ i9P 8�9 t & obi nor .
sa.w ncanon: 1'h®ne# ., 60;L ft '
ft.` ft
Femlitylltame Fece7i y ID#�ifapphcableY ft. ft
1 f33 fyxc� !` cft. ft
tr�a��� facer
21.REMAMO
Palocl+IdmtificahonNo.(PIIIN)
5b.Latitude and!o a in degrees/minutes/seconds or de ftid degrees:
(ifwall field,one lat/longis sufficient) ;.; , ` j 22.Certifica. n:k
1n e 5ignatnre of CertifiedWcU Contactor Date
6.Is(are)thewell(s): I�ermaaent or OTemporary � . :
By signing thisfatm,]hereby certify that the wells)was(were)constructed in accordance with
• r �ISANCAC 02C.0100 or I5A NCAC 02C.0200 Weil Construction Standards and that a copy
7.In thus a repair to an existing well: Oyes or �No
thUta,orrepalr.,fill oul brawn welt cansin+ctioa bl/armaUan and espldm`the nature of the of this record has bean provided id the
welt owner.-1
repatrwider$Zlremar secttanaronfhebacfrafthisform. 23.Site diagram or additional well details:
" A You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed--Loop G,a ermal Rrells h'avmg fhe same (add,See Over'in Remarks Bar).You may also attach additional pages if necessary.
construction,only 1 GW 1 is: dcIndicaie�TOTALNIJMBER of oVells
drilleds IM, 24.SUBtvrlT-re,L MTRUCTTONS
9.Total well depth below land surface*"` � ` A)
.�„ Submit this GVY-I within 30 days of well completion per the following:
For nmhiplewells/Lit all dept s,f dr�uent(acample 3(a)200 and 2®1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
ID.5tatie water levEl`below top,of casing. t` - (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater level is above rnsiirg vse +'�4r� +< /�^ F
E (y. Bit Off: Cs 0 O� �•24b.For Injection wells:Cdpy to Dw1:,Underground Injection Control(lUC)
I+1.Borehole diameter:' wf (in, Frog-an, MSC,Raleigh,INC 27699-1636
�� is
�AIR ROTARY
12.Well construction-meihod. r 14c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
eager rotary cable,direct push eta) county environmental health department of the county where installed
x
e� FOR WATER STJPPI,Y' ' ILS ONLY: 24d.For Water Wells yrodu�cim!over 100,000 GPD: Copy to DWR,CCPCUA
Permit Prog=41611 MSC,Raleigh,NC 27699-1611
s + 13e.Yield(gpm) ` ,,Method oftes`t Ga Y, f i �
a I �
i
70%HTH '- DATE SITE VISITED:
I3b.Disinfection lyp_e: -Amount�+r, ��� OZ p
pric•P• � � �� � -�O�w'jod �'°
VISITED BY: �o
_.... edp'R�,ryr� U dl,n.._..t..."tri:_:..a.._..._ric_.r�_�•.,:�1 t1n�t:a. T:.,.•.......a n�..,:r Reennrc.c Revie�d 6-A_9MR