GW1-2022-08920_Well Construction - GW1_20220912

STlkVC—T 1ON RE00 D f��=1� For Internal Use Only:
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1.well Cate Informntian: r
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(i n � Ga v� 14,WATER ZONES�,�� �>�9• $ 1 �-�
rFROm '-%s 'ATO'"t 'si,+ 3DnSCRD?TION » r°t tic x a
Well ContracwrName Q �'tt tt - n r a ia,
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NC Well Contractor Certification Number 15.OUTER CASIIYG•farmu]tie-rased s ORLEM if a licable Q
YADKIN WELL COMPANY,INC. rROM To DIAMETER T/�CKNES5 MATERIAL
ft, ft ' in.
Company Name 16•INNER CASING OR Tl1B1NG eothermal closed-loop)
2.Well Construction Permit FROM To DIAMLrrER I =CIOPES3 MATERIAL
ft it 1 m
Lis/all applicable well construction pennies(,e.to ,County,Sfate,V in. C-
ariance, d�'l7
in.
3.Well Use(cbeckwell use): ft.
.17.SCREEN
Water Supply Well: rRoni TO DIAMETER SLOT SIZE THICIOYESs Mprcnu,.
OAgricultaral ❑Municipal/Public
❑Geothermal(HeatinglCooling Supply) R<esiddntial Water Supply(single) 1 .
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrigation ❑Wells>100,000 GPD KSANDIGRgAVELrAC-K
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: , u❑Monitoring °� G n S la/i it Injection Well:❑AquiferRecharge SEP i QundwaterRemediation Ofa liable)
❑Aquifer Storage and Recovery) ❑Salin> arrier FROMTO TERIAL EMFLACEMENTMETHOD
K ft. ft
❑Aquifer Test Irp.,rrayrk , �tormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
under#21 Rematics FROM TO DESCRI MON color,hardnLu.saiVrack .. she,eta
❑Other
❑Geothermal(Heating/CoolingReturn) (explain ) ft R. �►� II!
4.Date Well(s)Completed: ?a �� Well IN R t 1(
Sa.Well I��eAfi^^• Phone # 33 L{ SGFa- /a
— er
a h •.
Facility/OwnNemd FacIIityID#(if applicable) M 1 10 , 'COAL /A oF
Pbysical Address,City,and* Zs d.J�R' M! /a
County tJ a by - x Parcel Identification No.(FIN)
3 ' -1 Dzu+<
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d
(ifwell field,one lat/loagis sufficient) 22.Certification:
N 21 /6 ye,Z W - -'
6.Is(arc)the well(s) r Signature of Certified Well Contractor Date
ermanent or ❑Temporary J -_
• By signing thisform,I hereby certify that the we11(s)was(were)cans6ucted in accordance with
7.Is this a repair to an e7ci4ting well: ❑Yes or N0 i, 15ANCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
thin is a repair,fdl out lmown well construction Information and explain the nature of the ofthis record has been provided to the well owner.
If
repair tinder#21 remarkrsection or on the backofthisform. d` 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).'Ypu may also at bLoh additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled— 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��` (ft•) Submit this GW-1 within 30 daya of well completion per the following:
For multiple wells list all depths J'�erent(=ample-3@200'and 2@1001
24a. For All Wells: Original Ifo m to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaier level is above casing,use"+" (� Q
Bit Off: V s U 6a 24h.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and pyuen-Loop Geothermal Return Wells:Copy to the
(it.auger,rotary,cable,direct push,etc.) county environmental health department of the county where msmued
la t
� FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produanS over 100,000 GPD: Copy to DWR,CCPCUA
1/12 r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 0q Method of test:
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DATE SITE VISITED: o .-�� '2 Z
13b.Disinfection type: 70 h HTH Amount:
-- VISITEt?BY: ///