GW1-2022-09487_Well Construction - GW1_20221014

7ONSTRUCTION RECORD(GW-1) For Internal Use only:
,;ontmetor Information: _ 'I, tt
3 ,(><Yr_( 1''iJ 19.WATER ZONES T"
Well Contractor Name FROM TO DYSCRIMON �—•
ays�a 770� ��-� �
NC Wen Comnetm Ce Nmnber IL . 3001L Owl
tor
MOU7'SRCA6AIGa,alti-naedwa➢5)OR LINER d• Gnhle 3
YADKIN WELL COMPANY,INC. FROM TO nGMETBR I TEXCENEas I MATERIAL (f
ft R in.
C�yName
SS/l/Q 16.D�IIVgfl CASII�IG ORTUBINC. tLerma 11gd-loo
2.Well Construction Permit#:_ Z` 7 FROM TO m�s. TfficZavassI MATSRreL
Lan all applicable well eanstrvu(onpemitr ge,DIC,Comity,State,V Hm,e,at,) tL 97 R 1/ ia' le a I 9ve-
3.Well Use(check well use): R R icy -
Water Supply Well: ]7.SCRW
FROM TO DIAMCM 6LOr6IIE THICKNISa MATERIAL
OAgrimhural OMimicipal/Public tt. ft. is _
CGeothermal(Heating/Cooling Supply) *asidantial Water Supply(single) ft
Dlndustrial/Cormnacial ORrsidential Water Supply(shared) I&GROUT
01ni 'on OWells>100.000GPD FImM TO MATERW. EMPLACEMENTaUSTROD&AMOUNT
Nan-Water Supply Well: rc as 'L 4olf pj
Vied
12
OMtmimriDg ❑Recovery n �, •
Injection Well:
OArliffwRecharge OGroundwater Remediation R fL
OA9uifer Storage and Recovery OSalm 19.SAND/GRAVEL PACKsfaliuble
ity Battier FROM Tr M&TERIAL I EMe AC33KI T 74=OD
OAqui&r Test EISturmwattr Drainage fL R
OExpelimeattil Technology OSubsidence Control ft it.
110eothemmal(Closed Loop) OTmeer 20.3DRUMINGLOGa#arh additional sheets if necarsaUl1
OOeothermal(Heating/CoolingRelma) ODlher(explain uudw#21 Ramada) FROM D il
DsscR8r2oN came,narua emvmrk elan eee
4.Date Wallis)Completed: ZAWcUIED# -� �r j' ftSa.Well Location: Phone # ,ey r� fL Ir
G
�)aL ,a0iA5- -773 — fL
fL L
FemlrylOw" ame FeemyM#(ifepArcable) ft R
rA 4M N C. $ 'fL fL c�
Physical Address,City.and Zip R ft
A S lP 21.RsafAaag �c
County Pastel IdentiSontim No,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(itwen fralrl,one tat/lo
ngis sufficient) 22.Certification:
(a
3- 444 3S�/5 N X i 474 U W �-i iW IN -20.h?—
6.L(are)the we1I(s):0ermanwt or OTemporary signantre of ad Wen Contractor Dora
BYx1rb,gthirform,Thereby mrrdy'hat the wall(s)was(were)cmratructed in orcordarre with
7.Is this a repair to an[slating well: OYes or 'A&o I5ANCAC o2C.0)Oo or ISA NCAC 02C.0200 Well Construction Standards and that a ropy
if this it a repair,fell out known well construction b1forn rtion and explain the nature of the ofthbs rerordhas bem provided to the well awns.
repair mdar#21 mnarkrsecdan or an the back ofthis form. 23.Site diagram or additional well details:
B.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
c®.strudhon,only 1 GW-1 is afedad. Indicate TOTAL NUMBER of wells (add'Sm Over'in Remmks Box).You may also attach additional pages if necessary.
drilled. ( 24.SUBMITTAL I NSTAUCIIONS
9.Total well depth below land surface: Li Xk A)
Forn a iple wells list all depths brihfermt(example-3 200'and2®1007 - Submit tide GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: - (fL) 24a. For All Wells: Original fora to Division of Water Resources (DWR),
Ifwoterl"al Is above coring,we"t„ lnfmmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1/0 (in.) Bit Off: I ( 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Prognan,1636 MSC,Raleigh,NC 27699-1636
I2.Well construction method: AIR ROTARY
(ie,roger,many,*IN direot prak atoJ 24c.For Water SuDDIv and Ooea-Loon Geothermal Return Well s•Copy to the
county environmental health department ofthe county where installed N
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells oroducine over 100 000 GPD:Copy to DWR,CCPCUA <
Lae.Yield(gpm) Z Method of teat:_Q!'Y PemntPmOFR n,1611 MSC,Raleigh,WC 27 9-1611 ¢ a
7D%HTH OZ DATE SITE VISITED: eC.
136.Diairfectian type: Amount: a
pri ry• N111110F VISITED BY: 1/06,
P.GW-7