GW1-2022-09488_Well Construction - GW1_20221014

+r�LLE, CONSTRUCTION RECORD(GIV-1) For Internal Use Only:
I.Well Contractor lnformntion;
AATHR
PR ZONES '7"
OM To DESCRIPnON y
Well Contractor Name ft. ) 7'j ft. Li
��ISaR ft. 377 R ai Gera► 't'
NC Weil Coams,,cs Ce(d5eatian Numb- 1SORCTOG for mDMrRsAL
1ffiFROM [a EeaMe
MATERGL
YADKIN WELL COMPANY,INC. ft. R in.
CampsnyyNwe //ems/�"X�[ 26.DVt1ER CASING ORTUDING thermal closed 3Z
2.Well ConstructicaPermit N: 31 7i-f /A >�DM To DIAME]8n TB:ICIQ7B39 aUTaaW.
R R in.
Las all applicable well mnrtrucltan permtu(La U1C,Cwnry,S(mS I'anancc,efe) 6 v (0
R ft.
1Well Use(cheekwdl use):
Water Supply Well: 27.SCREEN
FROM TO DIAMirER 51.rrI SIZE nDnOvcss MATERIAL p �
OAgricultmal OMunicipal/Public R. ft. iw `�
11C otheemal(Heating/Cooling Supply) -Wesidenfiel Water Supply(single) ft. ft, in N
01ndustrial/Commeroied ORcsidential Water Supply(shined) IL GROUT _ �
Obri 'on OWells>11)(1,000 GPD FROM TO MATERIAL EMPI.ACVKMT METHOD AAMOUNT
3
Non-Water Supply—Well. ft' ft' Idr P
oMonitoring ORecovery :3 R RI(PAr- 6rU' rtf 3bts 4
Injection Well: ft. R
OAquifer Recharge OGrormdwater Remediation Ig,SANDIGRAVEL PACK da livable k
OAquifer Storage and Recovery OSalmity Barrier InROM To MATEnr.r. EMPrwCEhmNTM]r OAquifer Test OStmmwater Drainage RROPxperimental Technology OSubsidence Control RROOeoth=al(Closed Loop) OTrsmer 20.DRUJ1KGLOG @!bate addixond sheets iface.saOGeoffimmal(Heating/Cooling Rehan) OOther(explain rider#21 Remmirs PROM TO DEsotnuON colon m.mrs..mafineA
n��, R'
4.Date Well(s)Completrd: ry �2 Well ID#,dd CTJs' /J R ya1R (, ti-P
5a.Well Location: Phone# fL R ft
FaedilylOwnerNeme � a (d'applicehl R R
R R R
Physiosl Address,(,l'ty.end Zip a 4 R R
-sK 2L 1tEMARKB R
Ca®ty Pored 7denti5aetion No.(M AA
5b.Latitude and longitude in degrem/minutes/seconds or decimal degrees: r`
(if we➢field,one lat/long is sufficient) 22.Certification: C V
3` .Z O �41L2 N V1 �3 3w W
4 iV A. .
6.IS(are)the well(s): Perm tumt or OTemporary Si�em of Ceei ed Well Conhactar Date
II
By rignbrg thisform,lh see by cert(fy ohm the well(s)was(were)cmrmw.dedin ocrordonee with
7.Is this a repair to an existing well: OYea or QN0 15ANCIC 02C.0100 or 15A NCAC 02C.0200 Well Construction Smudardr and ihof a copy
Ifihb Esa rzpalr, W1 ml h7awn well construction b(formalton mid eeViab the nature of the of thAr rzmrdhas ben prav(ded m the well owner.
repa b under#21 ramariasection or on The back ofthis form. m 23.Site diagra or additional well details:8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the beck of this page to provide additional well construction info
construction,only 1 OW-1 is ueeded. Indicate TOTAL NUMBBR of wells (add'See Over,in Remado;Box).You may also attach additional pages if necessary.
drilled: 7 24.SUBMUTAL INSTRUCTIONS
9.Total well depth below land surface: 1 Z� (ft) Submit this GW-1 within 30 days of well completion per the following:
m Forultip/s wells Ifrt all depfhs/fdfferenr(rs pie-3Q200'ondiotel
74a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: OO (ft-) Information ProorssjngUnit,1617 MSC,Raleigh,NC 27699-1617
If waur level U above main&use"+"
11.Borehole diameter- (ID,) Bit Off: 6, I i 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Releigb,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water ental h and d peo-Loop Geothermal Aemra Wells:Copy to the
(in eager.rotary,oable,dirempmh,eon.) county environmental health department of the covnTy where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodudn over 100 000 GPD:Copy to DWR,CCPCUA
S Method of test: q PeardProVmn,1611 MSC,Molgh, C 27 99-1 I1 S2N V ,i Cc'
13a.Yield(gpm) ae
13b.Disinfection type: 70%HTH Amount �S OZ DATE SITE VISITED: S `�js .iJZ�{�J aIIMl1
Vri t-A• VISITED BY: yB