GW1-2022-10298_Well Construction - GW1_20221114

NSMJIU-C RECORD(GW-1) For Internal Use Only:
1 pyeli:Contractoritnfornlntion:
ATER TO pESCRIPTiON
Well Contractor {t ft.
L :
uNC WeIl'Contractor CettiSoationNumba* 15 OUTER CA.3ING for multi-used wells ORLIl4F1t if a livable
,YADKIN WELL COMPANY,INC. FROM To pIAM]tTER TffiClovEss LKATERIAI.
.,tryst•,,,> ft. St in.
as Name
.amp y ; r /J FROM
IlVNER CASING OR TUBING' eothermal closed-loop)
Well Construction Permit#: •� (�}� FROM To DIAMETER TfficTavEss nuTERUL
:%"• Ltst all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft (, /y in. S 1 V L
ft. in.
3TWeli Use(cbeckwell use):
x a : 17.SCREEN
Water.,Supply Well: FROM TO DIAMETER Si OT SIZE THLCICNEss MATERIAL
■Aaicultaral ❑Mnnirapal/Public in.
„ s
❑�Geo#hermel(Heating/Cooling Supply) ,residential Water Supply(single) g {t, in.
c is
" ❑Industtral/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Iui On ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMMTAIETHOD&AMOUNT
�Ndn Water Supply Well: Z ft' Wo I ? D41
t,*, kc ❑Recovery tft. ft.
onrt°rI°g
Injection Well: ft. ft
{ElW *'Recharge ❑Groundwater Remediation
A4 r, U.SANDIGRAVM PACK(d a livable
❑AntlifCT Storage and Reccvmy ❑Salinity Barrier FROM I TO MATERIAL El«LACEMENTMETHOD
' OA mfet.Test ❑Stormwater Drainage
c q..
w +' fL ft.
❑Experimental Technology ❑Subsidence Control
w
t' ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG Mach additional sheets if necessa
FROM TO IIESCRIP'IION color,hnrdness,soil/rvtk e, .in rise,cft
� OQeothermal(Heating/Cooling Rebun) ❑other(explain under 421 Remade) ft. S0 fL o;�
' a drD`ate�Well(s)Completed: J0 27 - ll1D*4V- 7 / S 0 ft & ft' ,+C
ft fL
5a.W llaLoeation: Phone #
>: ft ft
ft-
/ 1
soil y/0 merName Facility M#(if applicable) fi E V i
c va
e, ft. it
.4 LULL
sisal ft
As,jcSty end zip s�ROD
, ft.
l/1 21.RIrMARICS .•,.
DWO DOG
Parcel Identification No.(PLAT)
Sb.Latitude an longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oat 1At11iingis sufficient) 22.Certification:
lv g 1 3j 3��-� W lc a ' Z2
Sign of Cd Well Contractor Date "
6.Is(are)the we➢(s)" ermanent or ❑Temporary
' By signing thisform,l hereby certify that the Well(s)was(were)constructed in accardance with
7.7s this epair to as e7asting well: ❑Yes oro I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that o copy
Z*fll
If lhts oxepalr,fill aul knmvn'well construction information and explain the nature of the of this record has been provided to the well owner.
repalrwtderi}21 mmkiseci►onoronthe back ofthisform. 23.Site diagram or additional well details:
6.For Geo robe/DPT or Closed-Loop Geothermal Wells haven the same You may use the back of this page to provide additional well construction info
p p g
indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,.only 1 GW=1 is needed...
dulled: J 24.SUBMITTAL INSTRUCTIONS
9.TO well depth below laud siirface: a L (ft) Submit this GW-1 within 30 days of well completion per the followings
tilli^b'WMR'fin ?
For MWliple.weils hr,all,depths ty digerent(example-3Q20D'and ZQ100�
S-0 24a. For All Wells: Original f form to Division of Water Resources (DWR),
0.Statie waterlleyr libelow top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above cosmg
F Bit Off: • 480 74b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
4.Borehole diameter (in) Program,1636 MSC,Raleigb,NC 27699-1636
ell cong.tic'ion method: AIR ROTARY 24c.For Water Supply and Open-'Loop Geothermal Return Wells:Copy to 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
eth Permit Program,1611 MSC,Raleigh,NC 27699-1611
Yield°(tipls) � Mod nftest•
v 70°la HTH OZ DATE SITE VISITED: el !�
s a 13bDISlnfechon type: Amount:
,t ;
€D BY: