GW1-2022-10287_Well Construction - GW1_20221114

i b ,CONSTWXTION RECORD (:GW-11 For Internal Use Only:
I.Well Contractor Information:
y� 14.WATER ZONES
Well Contract Name p� �y jIffOrkZ TO pESCRIPTIO jN�
D g ,- ft•
NC Well Contractor Certification Number NOV 1 ���' �� ft �•���� f/ �
1S.OUTER CASING for niulfi-cased wells ORLINF.R rf appU ble
YADKIN WELL COMPANY,INC. :'r34rs_3 l.inr FROM To nUMETER THICKNESS MATERIAL
ft. ft.
Company Name .7 , � ��� pwaoj '
26.INNER CASING OR TUBING(geothermal dosed-loop)
Jr�e:l 2.Well Construction Permit 2_cR _3C FROM TO DIAMETER THICKNESS TATERIAL
Llsl all applicable well construction permits(we EIIC,County,State,irariance,etc.) ft (� it ���-�� (sV� �
3.Well Use(checkwell use):
17•SCREEN
ft fr. in. 1 '
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICIMESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. I
❑Geothermal(Heating/Cooling Supply) E46,iduntial Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
, -9
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOIINT
Non-Water Supply Well: ft ft. / ew, ��.
❑Monitoring ORecovery / -ft ft.
Injection Well: e w�
19.SAND
❑AquifexRecharge ❑GroundwaterRem ft.
GRAVELPACK rfa livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL IZA LACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimeirtal Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) []Tracer 20.DRILUNGLOG attach additional sheets ifnecessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 REmarks) FROM TO DESCRIPTION color,hardness,so-Wrock e . sizr,etc. j
® ft. ft. �d�n
4.Date Well(s)Completed: -�� Well ID# /9'4-69, ft g0It- /31olev �� L S
5a.Well Location- Phone # ,9,Z-- 1/29-9"IJt ® ft
?rd L .3o, e S®7 fL
Facility/OwnerName Facilityll)#(ifspplicable) ft. ft
6
ft. ft.
�,� ��a���?�P�,� �{� ��'dY��c•a(lam � fr.
Physical Address,City,and* �j
21.REMARKS 11
County U A 11mrA Identification No.(PIN) nn�
Oli
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
U 3
os
6.Is(are)the well(s): E315ermanent or ❑Temporary Si re ofC ed Well Contractor Dater
By signing thisform,1 hereby ceri fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an eldsting well: ❑Yes or 9Nf o 15A NCAC 02C.0100 w•15A NCAC 02C.0200 Well Construction Mandards and that a ropy
If ibis is a repair,fill out known well construction infarmalion and explain the nature of the of this record has beet prcvided to the well owner.
repair under w21 remarks section or on the back ofthisform.
23.Site diagram or additionaIwelI details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction infu
construction,only I GW; is needed. Indicate TOTAL NUMBER of wells (add See Ovel'in Remarla Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: &,D�Q (ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiffe-t(example-3(a)200'ard2@100)
q.o 2rta. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaier level is above casing,use"+"
11.Borehole diameter (in.) Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department 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.Yield(gpm) Method oftest: aT�
13b.Disinfection type:
70%HTH Amount: / oZ DATE SITE VISITED: d 3
-------- --Pri cc-__ _ VISITED BY: �.i 4,oV:-