GW1-2022-09539_Well Construction - GW1_20221014

LL CONSTRUCTION RECORD ( W-1 a For Intemal Use Only:
1.Well Contractor Information:
Zia14.WATER ZONES I
Well Contractor Name TROM TO DESCRIPTION
NC Well 3036 cemseatinnxumber .. 400 ft• s 10 114e
IS.OUTER CASING for multi-cased wells ORLINER Cif a linable
YADKIN WELL COMPANY,INC. _ - ' `/ a" FROM To DTAMIITER Tincimss MATERIAL
ft. in.
Company Name OCT 1 2o2Z 16•INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Perm it#: __ t FROM TO XkN ITER THICIac,Ss T4ATERiAL
l�r.
List all applicable well construction per mits(4e�1IGrCouii[y Stn[e;T�rloryce, cf ft Ira ft-
t �� in. C' iSS'
3.Well Use(checkwell use): ft' ft• m. !Li1VL SWater Supply Well: 17.SCREENI7IOM TO METER SLOT SIZE THICIQ TERIAL
❑Agricultural unicipal/Public ft, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft n
❑Industrial/CommBrcial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMLTITMETHOD&AMOUNT
Non Water Supply Well: ft. s I ft. �-
OMonitoring ❑Recovery it ft,
Injection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
9•SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑SalinityBarriw FROM TO TERTAL E1l7PLACEIdENTMCrHOD
❑Aquifer Test ❑Storruwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft
❑Geothemmal(Closed Loop) ❑Tracer 20.DRIf1LINGLOG(attach additional sheetsifnecessary)
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) FROM To D&SCRIPTTON color,hnrdness,soiYrorktypr,gnana%c,ctc
4.Date Wells)Completed: all-l- z Z- Well ID#,AM—d 0 C, 3-SS-- ft 1 V® R �/• a Q A-
Sa.Well Location:
p� Phone # ��® Z90 � /V �.f•Sd
2 9 ft. d1oa f"
Facility/OwnerName Pa°ility ILA-(if applicable) Liu ft. 003 ft. Z ¢ 14 (l
1 t1 &dot r�1k rS`S.1(� ft. f ff.
Physical Address,City,and '
Fa 21.REMARKS
County �1 ParcelIdentifieation No.(P.1T1) r aoa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
36 a, 1 7737 N W' " 6y79r W ��
6.Is(are)the well(s):Kermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,1hereby cerlyy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing we11: ❑Yes or ko 15ANCAC 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 ofihis record has been provided to the well awner.
repair under21 renrarks section or on the bock of this form.
23.Site diagram or additional well details:
S.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
construction,only i,W-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. S
drilled: 24.SUBMMAL INSTRUCTIONS
9.Total well depth below land surface: 1=3 (ft.) Submit this GW-1 within 3D days of well completion per the following: Qi
For multiple wells list all depths ifdifferent(example-3 r©200'and 2©l000 n,
��� ft 24a. For All Wells: Original form to Division of Water Resources (DWR), 7J
10.Static casing:water level below top of ( ) Information Pro cessingUnit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use ".. /®03 tl
Il.Borehole diameter 'y (�I•�., (in,) Bit Off: 07T 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NCi27699-1636
12.WelI construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Lr.auger,rotary,cable,direct push,etc.) county environmental health departrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yjeld(gpm) Method of test: f9�
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
Sri rP-
VISITED BY:
F,,,,,,nmu-r . North Carolina Deoartment of Environmental Quality-Division of Water Resources Revised 6-6-7nIit